Every finding on record at The Good Shepherd Health and Rehabilitation Center

Based on observation, staff interviews, record reviews, facility policy reviews, and review of manufacturer instructions, the facility failed to maintain infection control standards related to proper hand hygiene, use of Enhanced Barrier Precautions (EBP), and during cleansing of resident-shared glucometers. This affected three residents (#7, #64, and #67) of 11 residents reviewed for infection control and had the potential to affect all residents residing in the facility. The facility census was 118. Findings include: 1. Resident #7 was admitted to the facility on [DATE] and had diagnoses that included Parkinson's disease, obstructive uropathy, and dementia. Review of the Resident's Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident had moderately impaired cognition, was dependent upon facility staff for transferring from chair to bed, and had an indwelling urinary catheter. Review of the care plan for Resident #7 states that the Resident requires evidence based (infection control) precautions related to the Resident having a percutaneous endoscopic gastrostomy (PEG) tube, sacral wound, and Foley (urinary) catheter use. A planned intervention states to wear gloves and gown with high-contact resident care. Observation of Resident #7 was conducted on 08/13/26 at 10:19 A.M. in the resident's room. Resident #7 was beside the bed in a Broda (a specialized medical positioning and mobility device designed to provide advanced posture support, pressure relief, and comfort for individuals with limited mobility) chair. Two Certified Nursing Assistants (CNA) were observed entering the room with a Hoyer (mechanical) lift to transfer Resident #7 from the chair to the bed. Resident #7 was transferred by the two CNAs. Neither CNA was observed wearing gloves or a gown during Resident #7's transfer. Interview on 08/13/26 at 10:21 A.M. with CNA #396 was conducted immediately after Resident #7's transfer observation. CNA #396 confirmed the two staff completed a Hoyer lift transfer and verified a gown and gloves were not worn for the transfer. Review of the facility policy titled Enhanced Barrier Precautions effective 03/26/24 revealed staff members providing high-contact care activities will follow Enhanced Barrier Precautions for patients who meet the criteria. The policy stated these precautions may be indicated for patients with wounds and indwelling medical devices. The policy states Enhanced Barrier Precautions require the use of gown and gloves during transferring. 2. Record review for Resident #67 revealed an admission date of 03/21/19. Diagnoses included type two diabetes mellitus with diabetic retinopathy. Review of the Quarterly MDS dated [DATE] revealed Resident #67 was cognitively intact, and had medically complex conditions including diabetes mellitus. Review of the physician orders revealed Resident #67 had an order dated 10/20/2021 for blood glucose level checks twice daily, before breakfast and supper, related to type two diabetes mellitus. Observation on 08/12/26 at 8:08 A.M. of a blood glucose check via a finger stick for Resident #67 completed by Licensed Practical Nurse (LPN) #804 revealed LPN #804 removed the glucometer which was unwrapped and lying in the top drawer of the medication cart on top of other glucometer supplies. LPN #804 did not clean the glucometer before using it to obtain a blood glucose level from Resident #67. LPN #804 entered Resident #67's room, donned disposable gloves, and pricked Resident #67's finger with a lancet to obtain the blood sample. The, using the glucometer, obtained a blood glucose result of 106. LPN #804 then administered Resident #67's Lantus (long acting insulin) by subcutaneous route per the physicians order. LPN #804 then gathered the glucometer and used insulin syringe and exited Resident #67's room while still wearing the soiled disposable gloves. After returning to the medication cart, LPN #804 laid the supplies on top the medication cart, reached in her pocket, obtained the keys, unlocked the medication cart, then removed the soiled gloves and used hand sanitizer to clean her hands. LPN #804 then took an alcohol wipe and wiped the glucometer for approximately 15 seconds with the alcohol wipe then put the glucometer back on top of the medication cart. Interview at the time of observation with LPN #804 confirmed she cleaned the glucometer with an alcohol wipe. 3. Record review for Resident #64 revealed an admission date of 03/22/19. Diagnosis included type two diabetes mellitus with diabetic neuropathy. Review of the care plan dated 11/16/21 revealed Resident #64 had the potential for altered blood glucose levels and signs and symptoms of hypo/hyperglycemia related to diabetes mellitus. Interventions included administering medications as per orders. Review of the physician orders revealed Resident #64 had an order dated 07/01/26 for Novolog (a short-acting insulin) flex pen four (4) units by subcutaneous injection before meals and at bedtime related to type two diabetes mellitus with hyperglycemia and an additional order for Novolog flex pen with the amount of units to be administered specified per a sliding scale based on the resident's blood glucose levels before meals and at bedtime. Review of the Quarterly MDS dated [DATE] revealed Resident #64 was cognitively intact, had medically complex conditions including diabetes mellitus and required assistance with activities of daily living. Observation on 08/12/26 at 8:22 A.M. of Resident #64's blood glucose assessment and medication administration revealed LPN #804 prepared Resident #64's insulin pen for administration, placed the insulin pen back in a clear plastic bag then obtained the same glucometer used for Resident #67 which was on top the medication cart. LPN #804 then went to Resident #64's room, placed disposable gloves on, pricked Resident #64's finger with a lancet to obtain blood sample using the glucometer and obtained a blood glucose result of 149. LPN #804 removed the insulin pen from the plastic bag and administered Resident #64's insulin injection then placed the insulin pen back in the plastic bag and placed the plastic bag under her armpit. LPN #804 then removed the glove from her right hand, carried the soiled glove with her left hand and the glucometer and lancet with her right hand, exited the room and returned to the medication cart without performing hand hygiene and with the insulin pen still under her armpit. LPN #804 then set the supplies on top the medication cart, removed the glove from her left hand, used hand sanitizer then placed the insulin pen still in the plastic bag back in the medication cart on top of several other insulin pens belonging to other residents. LPN #804 then took an alcohol wipe and wiped off the glucometer for approximately 10 seconds and placed it back on top the medication cart. Interview on 08/12/2026 at 8:35 A.M. with LPN #804 confirmed she did not clean her hands prior to exiting Resident #64 or #67's room, wore soiled gloves back to the medication cart for both residents, carried the insulin from Resident #64's room back to the medication cart under her armpit then placed it on top of other residents' insulins, and cleaned the glucometer with alcohol wipes. LPN #804 revealed she used the same glucometer for all her residents who require blood glucose checks. Interview on 08/12/26 at 5:00 P.M. with the Director of Nursing (DON) revealed staff should remove their soiled gloves and cleanse their hands before exiting a resident room. Nurses should not carry a resident's medication under their arm pit, and the facility used Micro Kill One Germicidal Wipes to disinfect glucometers between each use. Review of the facility policy titled, Using the Meter Memory undated revealed the materials needed were a validated disinfecting wipe. The meter should be cleaned and disinfected between each patient. To clean the meter, use a moist, not wet, lint free cloth dampened with a mild detergent. Wipe all external areas of the meter including both the front and back surfaces until visibly clean. To disinfect your meter, clean the meter with one of the approved disinfective wipes. Products which had been approved for cleaning and disinfecting of the meter included Micro Kill One Germicidal Wipes. Review of the Micro Kill One Germicidal Wipes undated directions for use revealed to disinfect hard, nonporous surfaces, use one or more wipes, as necessary to thoroughly wet the surface to be treated. Treated surface must remain visibly wet for one minute to achieve complete disinfection. Allow surfaces to air dry. Review of the facility policy titled, Handwashing Requirements dated 02/06/20 included hand hygiene is required upon and after coming in contact with a patients intact skin (e.g., when taking a blood pressure or lifting a patient) and before and after performing any invasive procedure (e.g. fingerstick blood sampling).

Based on observation, interview, record review and facility policy review, the facility failed to properly store and secure medications. This affected eight residents (#21, #32, #40, #67, #72, #76, #98, and #129) and had the potential to affect the residents residing on the Continuing Care Front Hall, Continuing Care Back Hall, and Memory Care units. The facility census was 118. Findings include: 1.Observation on 08/10/26 at 4:14 P.M. of medication storage with Registered Nurse (RN) Supervisor #375 of the Continuing Care medication storage refrigerator revealed there were two applesauce containers and four cans of beer sitting next to several Haldol (an antipsychotic medication) injections, insulin pens and rectal suppositories. RN Supervisor #375 confirmed food and drinks were not to be stored in the refrigerator with medications at the time of observation. 2. Record review for Resident #67 revealed an admission date of 03/21/19. Review of the physician orders for Resident #67 dated 06/23/26 revealed an order for Humalog Kwik Pen solution pen-injector 100 units per milliliter (ml), inject per a specified sliding scale (based on blood glucose result) subcutaneously after meals related to type two diabetes mellitus.Observation on 08/10/2026 at 4:22 P.M. of the Front Continuing Care medication cart with RN Supervisor #375 revealed Resident #67's Humalog Kwik Pen was partially used and had no delivery date. The label portion with the date was torn off and there was no opened date written on the insulin pen. RN Supervisor #375 revealed insulin pens were only good after being opened for 28 days and confirmed Resident #67's insulin pen had no dates.3. Record review for Resident #32 revealed an admission date of 04/23/25. Review of the physician orders for Resident #32 dated 04/23/25 revealed Resident #32 had an order for Aricept (also known by the generic name of Donepezil, a medication used to treat confusion, memory loss, or other signs of dementia) oral tablet 10 milligrams (mg) give one tablet by mouth one time a day for Alzheimer dementia with psychotic disturbance.Observation on 08/10/26 at 4:23 P.M. of the Front Continuing Care medication cart with RN Supervisor #375 revealed Resident #32 had a partially filled bottle of Donepezil 10 mg dispensed on 05/07/25 and had a use by date of 05/07/26. RN Supervisor #375 confirmed Resident #32's partially used bottle of Donepezil located in the medication cart was expired. 4. Record review for Resident #76 revealed an admission date of 06/15/24. Review of the physician orders for Resident #76 dated 10/06/24 revealed an order for Prevnar 20 intramuscular suspension prefilled syringe 0.5 ml (Pneumococcal 20-Valent Conjugate Vaccine), inject 0.5 ml intramuscularly one time only for vaccine for four days. An additional order for Resident #76 dated 09/23/24 included Flucelvax quadrivalent intramuscular suspension prefilled syringe 0.5 ml (Influenza virus vaccine tissue-cultured subunit quadrivalent), inject 0.5 ml intramuscularly one time only for vaccine for two days.Observation on 08/10/26 at 4:38 P.M. of the Memory Care medication room refrigerator with RN Supervisor #375 revealed Resident #76's Prevnar 20 0.5 ml single dose expired in 01/2026 and Flucelvax 0.5 ml single dose expired 06/02/25. RN Supervisor #375 confirmed the medication was expired at the time of observation.5. Record review for Resident #72 revealed an admission date of 01/04/24. Review of the physician orders for Resident #72 dated 05/07/24 revealed an order for Shingrix intramuscular suspension reconstituted 50 micrograms (mcg)/0.5 ml (Zoster vaccine recombinant adjuvanted), inject 0.5 ml intramuscularly one time only for vaccine for three days.Observation on 08/10/26 at 4:39 P.M. of the Memory Care medication room refrigerator with RN Supervisor #375 revealed Resident #72's Shingrix intramuscular injection set one powder and one solution delivered 05/07/24 expired on 04/2026. RN Supervisor #375 confirmed the medication was expired at the time of observation.6. Record review for Resident #40 revealed an admission date of 01/9/23.Review of the physician orders for Resident #40 dated 05/12/23 revealed an order for Nitroglycerin 0.4 mg, one tablet sublingually every five minutes as needed for chest pain. Instructions indicated to not exceed more than three doses and to call the physician after the third dose.Observation on 08/10/26 at 4:46 P.M. of the Memory Care medication cart with RN Supervisor #375 revealed Resident #40's partially used vial of Nitroglycerin sublingual 0.4 mg tablets expired in April 2026. RN Supervisor #375 confirmed the vial had been opened, was partially used, and was expired.7. Record review for Resident #21 revealed an admission date of 07/07/22.Review of the physician orders for Resident #21 dated 05/05/23 revealed an order for Nitroglycerin 0.4 mg, one tablet sublingually every five minutes as needed for chest pain. Instructions indicated to not exceed more than three doses and to call the physician after the third dose.Observation on 08/10/26 at 4:59 P.M. of the Continuing Care back hall medication cart with RN Supervisor #375 revealed Resident #21's partially used vial of Nitroglycerin sublingual 0.4 mg tablets expired in February 2026. RN Supervisor #375 confirmed the vial had been opened, was partially used, and was expired.8. Record review for Resident #98 revealed an admission date of 03/06/25.Review of the physician orders for Resident #98 dated 03/06/25 revealed an order for Nitroglycerin 0.4 mg, one tablet sublingually every five minutes as needed for chest pain. Instructions indicated to not exceed more than three doses and to call the physician after the third dose.Observation on 08/10/26 at 5:00 P.M. of the Continuing Care back hall medication cart with RN Supervisor #375 revealed Resident #98's partially used vial of Nitroglycerin sublingual 0.4 mg tablets expired in April 2026. RN Supervisor #375 confirmed the vial had been opened, was partially used, and was expired.9. Record review for Resident #129 revealed an admission date of 05/08/25 and a discharge date of 07/16/26.Review of the physician orders for Resident #129 dated 07/02/26 revealed an order for Lantus subcutaneous solution 100 units/ml (Insulin Glargine, a long-acting insulin), inject 10 units subcutaneously at bedtime for diabetes mellitus.Observation on 08/10/26 at 5:00 P.M. of the Continuing Care back hall medication cart with RN Supervisor #375 revealed Resident #129's Lantus insulin was in the medication cart partially used with no opened date. RN Supervisor #375 confirmed the insulin had been opened, was partially used and Resident #129 no longer resided at the facility.Interview on 08/11/2026 at 3:22 P.M. with DON revealed expired medications should not be in medication carts, medication storage rooms, or refrigerators. When a resident is discharged , the medication should be removed from the cart.Review of the facility policy titled, Medication Storage undated revealed medications will be stored in the original, labeled containers received from the pharmacy. Expired, discontinued, and or contaminated medications will be removed from the medication storage areas and disposed of in accordance with facility policy. Employee or resident food should not be stored in the medication refrigerator.

Based on record review, observation, and interview, the facility failed to develop and implement individualized activity programming for Resident #11, who resided in the memory care unit, and failed to ensure Resident #58 was provided meaningful opportunities for community outings and activities outside of the facility based on the resident's expressed interests and preferences. This affected two Residents (#11 and #58) of two residents reviewed for activities and had the potential to affect all 22 residents residing in the memory care unit. The facility census was 118. Findings include: 1.Review of the medical record for Resident #11 revealed an admission date of 02/27/25. Diagnoses included unspecified dementia, severe, with mood disturbance, unspecified dementia, moderate; generalized anxiety disorder; major depressive disorder; insomnia; and unspecified symptoms and signs involving cognitive functions and awareness. Review of the activities care plan dated 10/19/25 revealed the resident had the potential for alteration in scheduled and self-initiated events. The care plan goal was for the resident to verbalize enjoyment of at least one activity after participation. Interventions included assisting the resident in identifying activities of choice, familiarizing the resident with the environment and activities, offering invites and encouragement, praising efforts, providing assistance to and from activities, providing leisure materials as needed, and providing a monthly activity calendar. The activities care plan did not include any indication of Resident #11's activity preferences. There were no individualized activity interventions related to the resident's dementia, mood disturbance, anxiety, depression, behavioral needs, limited participation, refusals, or psychosocial well-being. Continued review of the care plan failed to reveal revisions after the resident returned from a psychiatric hospitalization with continued behavioral and psychosocial needs. Review of activity documentation dated 02/20/26 revealed the resident rarely participated in activities, would play ball toss at times, preferred to stay in the room, and only came out for meals. The documentation showed the resident had limited participation and specific activity preferences; however, the record failed to show a comprehensive individualized activity program was developed and consistently implemented to address those needs and preferences. Review of a Minimum Data Set (MDS) Section F activity preference document dated 03/09/26 revealed Resident #11's family or significant other's involvement in care discussions as the only identified preference. The document did not identify specific activity interests, preferred activities, refusal patterns, activity approaches, or individualized interventions to support the resident's cognitive, behavioral, emotional, or psychosocial needs. Review of the comprehensive MDS 3.0 assessment dated [DATE] revealed the resident interview for daily and activity preferences was not completed. The MDS directed staff to complete the staff assessment of daily and activity preferences. Review of the staff assessment revealed most daily and activity preference areas were marked No. Family or significant other involvement in care discussions was the only preference marked Yes. Review of the Multidisciplinary Care Conference dated 06/15/26 revealed the recreation summary identified the resident had been more engaged in activities and had participated in chapel, coloring, and some fitness activities. The goal was to continue offering engagement and providing support. The care conference also identified the resident resided on the memory care unit, had recently returned from a psychiatric stay, and continued to have behaviors. However, the activities care plan did not show revisions that addressed the resident's known activity preferences, low participation, psychiatric hospitalization, behavioral needs, or need for individualized activity approaches. Observation of Resident #11 on 08/10/26 at 10:38 A.M. revealed the resident was seated in the common area. The resident did not exhibit signs of distress or aggression during the observation. The observation did not identify individualized activity engagement or staff offering resident-specific activity interventions during the observation. Interview with Director of Recreation #304 on 08/13/26 at 9:40 A.M. revealed the only activity assessment completed for Resident #11 was the MDS Section F assessment. Director of Recreation #304 stated activity participation was tracked through a calendar in the electronic health record (EHR). Director of Recreation #304 stated if an activity was check marked, the resident participated, and if the calendar was blank, the resident did not participate. Director of Recreation #304 identified Resident #11 liked ball toss and coloring. Director of Recreation #304 stated staff attempted to engage the resident and used movement-based activities and nonverbal approaches when needed. Director of Recreation #304 did not identify a separate comprehensive activity assessment, a detailed individualized activity program, documented follow-up for refusals or non-participation, or activity care plan revisions following the resident's psychiatric hospitalization and return to the facility. Review of the facility policy titled Care Planning, effective 11/01/19, revealed a licensed nurse, in coordination with the interdisciplinary team, developed and implemented an individualized care plan for each resident to provide effective, person-centered care and necessary health-related care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. The policy further revealed care plans were to be updated on an ongoing basis as changes occurred and reviewed quarterly with the quarterly assessment. 2.Record review for Resident #58 revealed an admission date of 09/19/25. Diagnosis included Parkinson's and gastrostomy status. Review of the care plan for Resident #58 dated 09/22/25 revealed the resident preferred a combination of scheduled group activities and independent leisure activities based on interests and daily preferences. Interventions included assisting the resident in identifying activities of choice and offering invites and encouragement. Review of the Life Enrichment/Activities form for Resident #58 dated 09/23/25 revealed the activity pursuit pattern for Resident #58 included talking or conversing, arts/crafts, reading/writing, wheeled outside, and spiritual/religious activities. Review of the routines Resident #58 had was daily contacts with relatives or friends and going out at least one day a week. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #58 was severely cognitively impaired, had no impairment to upper or lower extremities, used a walker and or wheelchair for mobility and was dependent for wheelchair mobility. Interview on 08/10/26 at 3:00 P.M. with Resident #58 revealed the facility used to do a lot. When the old activity director retired, the facility stopped doing much outside of the facility anymore. Resident #58 stated the facility used to take residents out of the facility and go to games and all kinds of places, but not anymore. Resident #58 stated I can't remember the last time I got to go out on a drive or somewhere just to get out and enjoy something. I really miss it. Interview on 08/13/26 at 9:07 A.M. with Director of Recreation #304 revealed Resident #58 liked to go to chapel weekly and liked reading books. Review of the Activity calendar for August 2026 at the time of interview confirmed of the 10 weekend days (Saturdays and Sundays) six had no activity staff present. Director of Recreation #304 revealed activities on those days were self-initiated. Director of Recreation #304 revealed the facility did two outings a month. This months outings included was shopping on the 26th which they could only take three residents, and a scenic drive the 31st which they could take up to 10 residents. That would be a total of 13 residents to go on outings a month. The facility census was 118. Director of Recreation #304 revealed Resident #58 had not expressed he wanted to go on outings. The Life Enrichment/Activities form where Resident #58's routines were listed were reviewed and indicated the resident enjoyed daily contacts with relatives or friends and going out at least one day a week. Director of Recreation #304 revealed she did not know when Resident #58 was last invited to go out on a drive with activities. Interview on 08/13/26 at 11:10 A.M. with Licensed Practical Nurse (LPN) #323 revealed Resident #58 could absolutely go on a drive or to an event with activities. Resident #58 had a Percutaneous Endoscopic Gastrostomy (PEG) tube (through which the resident receives enteral nutrition and/or medications) but stated the facility could get orders to hold the tube feeding so he could go on an activity outing and stated that would be no problem.

Based on interview, medical record review, and review of the Consultant Pharmacist Recommendation to Physician reports, the facility failed to ensure written Physician/Certified Nurse Practitioner (CNP) orders were accurately transcribed into the electronic medical record. This affected one resident (#67) of five resident records reviewed for unnecessary medications. The facility census was 118. Findings include: Record review for Resident #67 revealed an admission date of 03/21/19. Diagnoses included depression and anxiety disorder. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #67 was cognitively intact, had medically complex conditions including schizophrenia, anxiety disorder and depression. Resident #67 received a scheduled pain medication regimen and had pain almost constantly. a. Record review of the Consultant Pharmacist Recommendation to Physician for Resident #67 with a medical record review date of 02/23/26 revealed the resident had an order for Diclofenac (Voltaren) gel (a topical nonsteroidal anti-inflammatory drug (NSAID) used to relieve joint pain and inflammation caused by osteoarthritis in areas like the hands, knees, and ankle). The recommendation requested for the prescriber to please provide a dose and included the suggested dosing: for lower extremities: Apply four grams every six hours not to exceed 16 grams a day to any single joint. Review of the Physician/Prescriber Response dated 03/03/26 completed by Certified Nurse Practitioner (CNP) #806 revealed the prescriber agreed. Registered Nurse (RN) Supervisor #375 documented Noted with her signature on the report on 03/05/26.Review of the physician order for Resident #67 placed in the electronic medical record by RN Supervisor #375 on 03/05/26 revealed the order for Voltaren external gel 1% apply to right knee topically two times a day for pain for lower extremities. Instructions included to apply four grams, not to exceed 16 grams a day to any single joint. The order was timed to be administered at 10:00 A.M. and 10:00 P.M.Review of the Medication Administration Record (MAR) located in the electronic medical record for Resident #67 revealed the Voltaren external gel 1% apply to right knee topically two times a day for pain for lower extremities apply four grams no to exceed 16 grams a day to any single joint was applied at 10:00 A.M. and 10:00 P.M. from 03/05/26 at 10:00 P.M. through 08/12/26. Interview and record review on 08/12/26 at 12:13 P.M. of the Consultant Pharmacist Recommendation to Physician for Resident #67 dated 02/23/26 and the electronic medical record for 03/05/26 to current for Resident #67 with the Director of Nursing (DON) confirmed the Voltaren external gel was transcribed incorrectly into the electronic medical record by RN Supervisor #375 on 03/05/26. The DON confirmed Resident #67 was to receive the Voltaren gel four grams every six hours per CNP #806's orders, not twice a day.b. Record review of the Consultant Pharmacist Recommendation to Physician for Resident #67 with a medical record review date of 07/22/26 revealed this resident had been taking Cymbalta (an antidepressant medication) 60 milligrams (mg) since 12/2025 without a gradual dose reduction (GDR). Could we attempt a dose reduction at this time to verify this resident is on the lowest possible dose? If not, please indicate response below. The response dated 08/06/26 completed and signed by CNP #805 revealed Change therapy as follows: Cymbalta 50 mg The hand written order for the Cymbalta appeared to have first been written as a 30 mg then the three was made into a five and traced over the five multiple times. RN Supervisor #375 documented Noted with her signature on 08/08/26.Review of the physician order for Resident #67 placed in the electronic medical record and MAR dated 08/06/26 with the DON revealed Cymbalta oral capsule delayed release particles 30 mg give one capsule by mouth one time a day for depression. The MAR indicated the medication Cymbalta 30 mg was given on 08/06/26 then was discontinued on 08/06/26 and rewritten for Cymbalta oral capsule delayed release particles 20 mg give one capsule by mouth one time a day for depression and initiated on 08/07/26 then continued daily. The DON revealed she was unsure why the Cymbalta was written by RN Supervisor #375 for 30 mg then discontinued and written for 20 mg when the order documented by CNP #805 appeared as 50 mg.Interview and record review of the Consultant Pharmacist Recommendation to Physician for Resident #67 (with a medical record review date of 07/22/26) on 08/12/2026 at 12:21 PM with CNP #805 and the DON present revealed CNP #805 verified she wrote the Cymbalta 30 mg on 08/06/26 then wrote over the three to make it a five and verified Resident #67 was supposed to be receiving Cymbalta 50 mg (not 20 mg or 30 mg as indicated on the MAR) daily for depression beginning 08/06/26.

Based on record review and interview, the facility failed to provide physician ordered restorative programs for one resident (#34) of one reviewed for restorative range of motion interventions. This had the potential to affect nine additional residents identified by the facility as having physician orders for restorative programs. The facility census was 118. Findings include: Record review for Resident #34 revealed an admission date of 10/26/21. Diagnoses included osteogenesis imperfecta, contractures of muscles in multiple sites, scoliosis, quadriplegia, and acute and chronic respiratory failure. Review of the care plan revised 02/09/23 revealed Resident #34 had potential for fall related to quadriplegia/myoneural disorder/osteogenesis imperfecta. Interventions included to assist Resident #34 with bilateral upper extremity (BUE) passive range of motion (PROM) three times, 15 repetitions (reps), for 15 minutes a day at least three times a week. Review of the physician orders for Resident #34 dated 06/16/26 revealed to assist resident with BUE PROM three times, 15 reps, and bilateral lower extremity (BLE) PROM three times, 15 reps, for 15 minutes a day at least three times a week. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #34 was cognitively intact, had impairment on both sides of the upper and lower extremities, used an electric wheelchair for mobility, and was dependent for eating, toileting hygiene, bathing, personal hygiene, bed mobility and chair/bed to chair transfers. Review of the Point of Care (POC) documentation in Resident #34's electronic medical record (EHR) for 07/14/26 through 08/07/26 revealed on 07/15/26 and 07/16/26 Resident #34 received 15 minutes of BUE PROM three x 15 reps and BLE PROM three x 15 reps for 15 minutes a day. The remainder of the days (07/14/26 and 07/20/26 through 08/07/26) were documented as not applicable.Interview on 08/10/26 at 1:39 P.M. with Certified Nursing Assistant (CNA) #408 revealed the facility used to have a Restorative Aide until the new company purchased them and did away with the position without ever telling the staff or residents why. CNA #408 stated, The residents need restorative, no one is doing it now.Interview on 08/11/26 at 1:53 P.M. with CNA #516 revealed she was Resident #34's primary CNA and confirmed she did not do any BUE or BLE PROM with Resident #34 and revealed no residents received any restorative programs anymore.Interview on 08/11/26 at 3:31 P.M. with the Director of Nursing (DON) revealed the facility's restorative program is still there but the Restorative Aide had been pulled to the floor and those programs transitioned to the floor. Each program was placed in the Point of Care (POC) section of the EHR. The DON stated the programs were general ROM and walk to dine programs. The DON revealed the CNAs on the floor were supposed to be doing the restorative programs for the residents since the Restorative Aid position was removed a few weeks ago. Interview on 08/11/26 at 4:05 P.M. with CNAs #422 and #516 revealed the restorative programs were in the electronic medical records under POC. CNA #422 and #516 revealed the Restorative Aid used to complete and sign the ROM programs off for all residents in POC who had restorative orders, but now that position was taken away, no one was completing and no one was signing off the programs as completed for Resident #34. Interview on 08/11/26 at 4:08 P.M. with Resident #34 revealed he use to get restorative range of motion, but he no longer received the restorative care. This deficiency represents non-compliance investigated under Complaint Number 3124550.

Based on medical record review, interview, and facility policy review, the facility failed to ensure appropriate monitoring of an indwelling urinary catheter was provided to Resident #4. This affected one Resident (#4) of six residents reviewed for urinary catheters. The facility census was 118.Findings include: Review of the medical record for Resident #4 revealed an admission date of 07/31/25 and diagnoses including quadriplegia, tracheostomy status, dependence on respirator ventilator status, neuromuscular dysfunction of bladder, and presence of urogenital implants.Review of physician's order dated 07/31/25 revealed to change Resident #4's Foley (a thin, flexible tube inserted through the urethra into the bladder to drain urine continuously) catheter tubing and bag once a month, an order to change foley catheter as needed for blockage or leaking, and an order for Foley catheter care every shift.Review of the plan of care dated 08/01/25 revealed Resident #4 was at risk for potential complications related to catheter use. Interventions included catheter care as ordered, change catheter and tubing as ordered, check tubing for kinks each shift, monitor for infection, monitor for pain and discomfort related to catheter, and monitor output each shift. Review of a progress note dated 04/14/26 revealed a Certified Nursing Assistant (CNA) reported leaking around Resident #4's catheter. Resident #4's catheter was replaced with resistance noted and there was no urine noted to return. Resident #4's catheter was flushed with normal saline and clotting was noted. Return of yellow urine with sediment was noted following the flush.Review of a progress note dated 04/25/26 revealed Resident #4's catheter was found lying on the bed and had been pulled out with the balloon still inflated. Resident #4's catheter was replaced with little tension, was flushed, and flowing dark yellow urine.Review of a progress note dated 05/17/26 revealed Resident #4's catheter was flushed and was malodorous. The urine in the bag appeared to be cloudy and dark yellow in color. Urine output was 1200 milliliters (ml).Review of an administration note dated 05/27/26 revealed Resident #4's catheter was flushed for blockage or leaking with effective results.Review of a progress note dated 05/27/26 revealed the NP was updated on resistance with flushing Resident #4's Foley catheter with normal saline. The NP gave a new order to change the flush to 0.25 percent Acetic acid twice daily.Review of a follow up progress note dated 05/27/26 revealed staff reported to Nurse Practitioner (NP) that Resident #4's Foley catheter had been difficult to flush. The NP ordered Acetic acid flushes two times per day, continue daily care, and to trend input and outputs. Review of the Treatment Administration Record (TAR) dated May 2026 revealed Resident #4's catheter was replaced on 05/29/26. Review of a progress note dated 06/08/26 revealed Resident #4 had a rusty-colored, mucus-like substance at the bottom of his urinary drainage bag. The NP gave an order to obtain a urinalysis, obtain white blood cell count, and hold Apixaban (an oral anticoagulant medication) until assessment.Review of an acute care note dated 06/09/26 revealed staff reported Resident #4 developed hematuria over the past 24 hours. Staff denied acute trauma at site. Resident #4 had a chronic Foley catheter related to a spinal injury. There were no documented fevers and staff changed the Foley catheter. The note indicated the NP was awaiting urinalysis results, Resident #4 declined acute complaints, and amber colored urine was present upon examination.Review of a follow up note dated 06/11/26 revealed Resident #4 had one episode of self-resolving hematuria prompting laboratory review. The Urinalysis results revealed Resident #4 was likely colonized (indicating the presence of bacteria that are not causing an active infection or acute symptoms). The note indicated the resident declined acute complaints, the urine color was amber upon examination, and the resident's vital signs were stable. Review of a Skin Observation Tool dated 06/18/26 revealed a nursing assistant reported Resident #4 had new area to left hip. An abrasion to the left hip was noted with heavy serous drainage. There was also a noted skin tear to Resident #4's testicles. Further assessment noted a large, red abscess (a swollen, localized pocket of pus and tissue that forms when body was trying to fight off infection) to the bottom of testicles with heavy amount of serosanguinous drainage. NP assisted with assessment and it was noted when Resident #4 urinated urine expressed from two areas within the abscess.Review of Change in Condition Evaluation dated 06/18/26 at 10:45 AM revealed the wound nurse observed a new abscess to scrotum. NP assessed area and while assessing Resident #4 urinated and urine was noted to shoot out of the abscess. Resident #4 noted to have foley catheter. The NP was in to assess and gave an order to send Resident #4 to the emergency room for further testing.Review of acute care note dated 06/18/26 revealed NP assessed Resident #4 for abscess on the scrotum. The NP described the area as circular, raised, nickel sized abscess with purulent drainage. NP reported the site leaked urine when voiding. The NP noted Resident #4 had a history of infected hairs and abscess which usually self-resolved. The NP noted increased swelling around penis and scrotum. There was concern for fistula (an abnormal tunneling or connection between two body parts often as results from infection, inflammation, or injury) formation and possible ischemia due to swelling. Resident #4 was sent to the emergency room for further intervention.Review of hospital history and physical assessment dated [DATE] revealed Resident #4 arrived at the hospital due to concern for urethrocutaneous fistula (an abnormal tunnel or opening between the urethra (the tube carrying urine from the body) and the skin of the penis or perineum) to the scrotum. Urology was consulted. Resident #4 reported consistent leakage around the urinary catheter for one to two weeks. There was leakage from his scrotum. Resident #4 was afebrile and hemodynamically stable. A Computed tomography (CT) revealed contrast was noted to extend from the inferior aspect of the penile urethra tracking to the skin surface of the scrotum, compatible with urethral-cutaneous fistula. It was noted the foley catheter was malpositioned with the balloon about the membranous urethra. Resident #4 required transfer to the intensive care unit (ICU) for ventilation needs.Review of hospital urology consult note dated 06/19/26 revealed the exam showed traumatic hypospadias (the underside of the urethra split and urinary opening moved back towards the base of the penis) from chronic catheterization. Urine was cloudy yellow with fibrinous sediment. There was a small boil noted with pinpoint drainage hole with purulent material expressed. There was serous fluid leaking from the sinus tract. CT results were reviewed and there was a noted fistula from bladder to scrotum. Urology performed a procedure with first attempted catheterization there was difficulty noted and inability to advance into the bladder. A cystoscopy was inserted. The urethra was noted to be distended with bullous edema (fluid-filled blisters) throughout the membranous portion, there was noted incompetent sphincter and fibrinous tissue and scarring consistent with prior foley trauma. The bladder was severely trabeculated (thickening of bladder wall) and diffusely erythematous consistent with chronic infection and high pressure voiding. Findings were consistent with chronic foley malpositioning in the membranous and bulbar urethra which may explain the patient's recent worsening of bladder spasms and contributing to early fistula formation. A new Foley catheter was placed with urine return. Review of an admission note dated 06/24/26 revealed Resident #4 returned to the facility from the hospital with a suprapubic catheter (a thin tube placed directly into your bladder through a surgically-created opening which bypasses the urethra). Interview on 08/11/26 at 9:44 A.M. with Resident #4 revealed he had noticed urine leaking from his catheter. Resident #4 reported he had to spent six days in the hospital and believed the facility had not inserted his catheter correctly. Interview on 08/12/26 at 9:33 A.M. with Registered Nurse (RN) #505 revealed on 06/18/26 she was called to the room as it was thought Resident #4 had a fistula. RN #505 stated urine was spraying from around the catheter. RN #505 reported a history of issues with Resident #4's catheter, including sediment, difficulty catheterizing him, and leakage around the catheter. RN #505 stated nursing had to flush the catheter on a regular basis. RN #505 stated Resident #4 needed a suprapubic catheter. RN #505 stated the nursing assistants emptied the catheter bag, however there was no output monitoring documented in the resident's record. RN #505 stated the nursing assistants would let the nurse know if there were any issues.Interview on 08/12/26 at 10:00 A.M. with NP #800 revealed she was notified on 06/18/26 that Resident #4 had a wound and she was needed for evaluation. NP #800 stated upon evaluation, she observed a dime to quarter sized erosion on Resident #4's scrotum which was leaking urine from the site. NP #800 stated she gave order to send Resident #4 to the hospital. NP #800 reported Resident #4 was dealing with intermittent pain and discomfort prior to 06/18/26. NP #800 stated staff should be performing daily hygiene care to the catheter site and notifying her of any changes. NP #800 indicated she was not sure what the exact procedure of the facility was, but she expected nursing aides would be documenting urinary outputs from the catheter. NP #800 indicated the nurses should check for proper placement of catheter by awaiting urine return.Interview on 08/12/26 at 10:05 A.M. with RN #600 revealed she had to encourage Resident #4 to go to the hospital on [DATE] as he did not want to go. RN #600 indicated she did not assess the area. RN #600 stated nursing assistants performed catheter care every shift, emptied catheter bag, and performed a final urinary output count at the end of the shift. RN #600 indicated she was unsure where the nursing assistants were documenting urinary output.Interview on 08/12/26 at 11:11 A.M. with Director of Nursing (DON) revealed the facility only monitored urinary outputs if there was a problem. The DON did not specify what a problem would be when questioned.Interview on 08/12/26 at 11:50 A.M. with RN #445 revealed she was unaware of any trauma or issues with Resident #4's indwelling urinary catheter.Interview on 08/12/26 at 11:53 A.M. with Certified Nursing Assistant (CNA) #422 revealed she was unaware of any trauma with Resident #4's catheter. CNA #422 stated Resident #4's catheter had been leaking for a while prior to 06/18/26. CNA #422 stated the nursing assistants perform catheter care and empty the catheter bag. CNA #422 stated they report any unusual color or odors to the nurse. CNA #422 stated they do not monitor output on a regular basis.Interview on 08/12/26 at 3:45 P.M. with RN #405 revealed she was the facility's wound nurse. RN #405 stated on 06/18/26 she assessed Resident #4 and observed a bump that appeared to be an abscess on his testicle. It was red and swollen with purulent drainage. RN #405 stated when Resident #4 urinated, urine expelled from the abscess. RN #405 stated she was aware Resident #4's catheter had been leaking for some time prior to the abscess forming.Review of facility policy for care and services dated 01/29/24 revealed the facility would follow current standards of practice and would follow reference manuals for nursing services and skills.Review of reference manual for insertion of straight or indwelling urinary catheter revealed upon insertion ensure there was no leakage from the catheter or tubing connections, ensure there was no pain or discomfort, monitor for output, ensure catheter had been secured, and record observations during insertion and care of catheter.

Based on record review, observation, interview, and policy review, the facility failed to ensure Resident #27's significant weight change was reweighed, assessed, monitored, investigated, and followed up on to maintain acceptable parameters of nutritional status. This affected one resident (#27) of five residents reviewed for nutrition. The facility census was 118. Findings include: Review of the medical record for Resident #27 revealed an admission date of 06/18/26. Diagnoses included atherosclerotic heart disease of native coronary artery without angina pectoris, hypertensive heart disease with heart failure, chronic kidney disease, obesity, gout, muscle weakness, type two diabetes mellitus with chronic kidney disease, chronic kidney disease stage 3b, peripheral vascular disease, venous insufficiency, acute kidney failure, pressure ulcer of the right heel stage 4, and other medical conditions affecting skin integrity, healing, mobility, pain, and nutrition.Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #27 was assessed through the Nursing Home Comprehensive MDS item set and the assessment was an admission assessment. The MDS triggered assessment areas relevant to the resident's care needs, including functional status, skin/wound risk, nutrition, and clinical monitoring.Review of the Care Area Assessment (CAA) worksheet dated 06/26/26 revealed Resident #27 required assistance with self-care and mobility tasks. The CAA worksheet identified ADL-related needs including oral hygiene, toileting hygiene, upper body dressing, lower body dressing, putting on/taking off footwear, personal hygiene, rolling left and right, and sit-to-lying. The CAA supported the resident had functional limitations requiring staff assistance and care planning.Review of the weight summary revealed Resident #27 had a documented weight of 269.0 pounds on 06/18/26 and a documented weight of 332.0 pounds on 07/06/26. This reflected a significant weight gain of 23.42 percent (%) in less than 30 days. There was no additional or corresponding information to indicate whether the weight change was accurate, clinically expected, related to fluid status, related to equipment or weighing method, or related to another condition requiring intervention.Review of meal intake documentation for the 30-day look-back period showed meal intake was monitored. From 07/14/26 through early August 2026, most documented meal-intake entries were in the 76-100% range, with some entries in the 51-75% range or lower, and occasional 'resident refusal' or 'resident not available' entries. Review of fluid intake documentation showed staff documented oral fluid intake in milliliters during the review period.Continued review of the medical record failed to reveal documentation showing increased weight monitoring was implemented or that the resident had been reweighed after the significant weight change was identified. There was no evidence the interdisciplinary team (IDT) reviewed Resident #27's significant weight to attempt to determine the cause for the weight gain. There was no indication the resident's nutrition care plan was revised to address the significant weight change, including additional monitoring, reweighs, or follow-up interventions. Interview with Dietitian #671 on 08/12/26 at 9:48 A.M. revealed the dietitian was aware of Resident #27's significant weight change. Dietitian #671 stated the resident had swelling on admission and that the swelling had greatly resolved, which contributed to the weight change. Dietitian #671 stated the weight change was expected based on the resident's clinical status. During the same interview, Dietitian #671 was asked whether weights should be checked more regularly to confirm the significant weight change was related to resolved swelling and not another cause. Dietitian #671 stated, That's a good idea. I will implement that after the August weight if there is a significant amount of weight loss. The interview confirmed additional weight monitoring had not already been implemented at the time the significant weight change was identified.Review of the facility policy titled Weight Monitoring and Tracking, effective 01/29/24, revealed the facility had a system in place to weigh, monitor, and track resident weights. The policy directed residents would be weighed on admission/readmission and weekly for four weeks thereafter or until the interdisciplinary team determined weight was stable, then monthly thereafter. The policy directed weights would be reverified when a weight variance of five pounds from the last weight occurred and/or when a significant weight change was identified. The policy identified significant weight change as 5% in one month, 7.5% in three months, or 10% in six months. The policy further directed the team would notify the provider and responsible party of significant weight changes, investigate possible causes of the weight change, discuss interventions, and document a progress note.

Based on record review, observation, staff interview, and review of manufacturer's instructions for administering insulin using an insulin pen, revealed the facility failed to administer medications per the physicians orders for two residents (#35 and #64) of eight residents observed and reviewed for medication administration. Out of 29 opportunities, two errors were identified resulting in a medication error rate of 6.9%. The facility identified an additional 14 residents (Residents #7, #10, #12, #19, #27, #40, #54, #57, #67, #74, #75 #79, #94, and #114) who received insulin pen injections and also had the potential to be affected by the deficient practice. The facility census was 118. Findings include: 1. Record review for Resident #64 revealed an admission date of 03/22/19. Diagnosis included type two diabetes mellitus with diabetic neuropathy. Review of the care plan dated 11/16/21 revealed Resident #64 had the potential for altered blood glucose levels and signs and symptoms of hypoglycemia (low blood glucose levels) and hyperglycemia (elevated blood glucose levels) related to diabetes mellitus. Interventions included administering medications as per orders.Review of the physician orders revealed Resident #64 had an order dated 07/01/26 for Novolog (a short-acting insulin) flex pen four (4) units by subcutaneous route before meals and at bedtime related to type two diabetes mellitus with hyperglycemia. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #64 was cognitively intact, had medically complex conditions including diabetes mellitus and required assistance with activities of daily living. Observation on 08/12/26 at 8:22 A.M. of medication administration revealed Licensed Practical Nurse (LPN) #804 prepared Resident #64's insulin for administration. LPN #804 obtained Resident #64's Novolog flex pen, placed a new needle on the tip of the flex pen then primed the pen with one unit of insulin. The observation revealed no insulin was observed at the tip of the needle after priming. LPN #64 then dialed in four units of insulin and administered the insulin to Resident #64.Interview on 08/12/2026 at 8:35 A.M. with LPN #804 following the observation confirmed she used one unit of insulin to prime Resident #64's Novolog insulin pen and confirmed there was no visible insulin at the tip of the needle after priming the insulin pen. 2.Record review for Resident #35 revealed an admission date of 04/16/26. Diagnosis included type two diabetes mellitus. Review of the care plan dated 04/16/26 revealed Resident #35 was at risk for complications related to the use of hypoglycemic medications. Interventions included to administer medications per the physician orders.Review of the Quarterly MDS dated [DATE] revealed Resident #35 was cognitively intact, had medically complex conditions including diabetes mellitus and required assistance with activities of daily living. Review of the physician orders for Resident #35 revealed an order dated 07/31/26 for Humulog (a short-acting insulin) solution pen injector, inject five units by subcutaneous route with meals for diabetes mellitus type two in addition to the sliding scale. Continued review of the the physician orders for Resident #35 revealed an order for Humalog insulin per sliding scale (with the amount to be given specified and based on the resident's blood glucose levels); the order stated that for a blood glucose result between 201 and 250, to administer four units. Observation on 08/12/2026 at 8:42 A.M. of medication administration revealed Registered Nurse (RN) #445 removed Resident #35's Humulog insulin pen from the medication cart. RN #445 placed a new needle on the end of the insulin pen and confirmed Resident #35's blood sugar was 215. RN #445 then dialed the insulin pen to nine units of insulin. RN #445 did not prime the insulin pen and administered the insulin to Resident #35. Interview on 08/12/26 at 8:46 A.M. with RN #445 confirmed she had not primed the insulin pen prior to administering the insulin to Resident #35 and revealed she usually primed insulin pens with one or two units, but this time she did not. Review of the manufacturer's instructions for priming insulin pens titled, Instructions for Use undated revealed priming your pen means removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. To prime the pen, turn the dose knob to select two units. Hold the pen with the needle pointing up. Tap the cartridge holder gently to collect air bubbles at the top. Continue holding your pen with the needle pointing up. Push the dose knob in until it stops, and 0 is seen in the dose window. Hold the dose knob in and count to five slowly. You should see insulin at the tip of the needle. If you do not see insulin, repeat the priming steps but not more than four times.This deficiency represents non-compliance investigated under Complaint Number 3124550

Based on observation, interview, and record review, the facility failed to honor dietary choices for Resident #12. This affected one resident (#12) of three residents reviewed for choices. The facility census was 118.Findings include: Resident #12 was admitted to the facility on [DATE] and had diagnoses that included end stage renal disease, Type I Diabetes Mellitus, and congestive heart failure.Review of Resident #12's Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated Resident #12 had intact cognition and required set up assistance for eating.Review of the medical record for Resident #12 revealed an undated document titled Diet Requisition Form. The document stated Resident #12 did not want or like scrambled eggs and documented her request for hard boiled eggs.Observation on 08/12/26 at 8:42 A.M. revealed Resident #12 was eating breakfast in her room. Scrambled eggs were present on the resident's plate. An interview with Resident #12 at the time of observation revealed she had ordered a hard boiled egg which was listed on her meal ticket. Record review of the meal ticket dated 08/12/26 revealed for the breakfast meal Resident #12 had ordered one hard boiled egg. Interview on 08/12/26 at 8:45 A.M. with Certified Nursing Assistant (CNA) #396 confirmed there were scrambled eggs on Resident #12's plate.Interview on 08/12/26 at 9:02 A.M. with Dietary Aide (DA) #652 revealed DA #652 viewed the document titled Diet Requisition Form for Resident #12 and confirmed Resident #12 was documented to not want or like scrambled eggs.Review of the facility document titled Resident Rights Acknowledgement updated 09/2023 revealed Residents had the right to make independent choices and personal decisions.This deficiency represents non-compliance investigated under Complaint Number 3124550.

Based on infection control tracking, staff interview, and policy review, the facility failed to follow antibiotic stewardship practices in prescribing antimicrobials. This affected 17 (Resident #6, #7, #9, #21, #27, #40, #51, #55, #69, #57, #70, #73, #76, #78, #83, #101, and #107) of 57 resident entries for antimicrobial treatments initiated in May and June 2024. The facility census was 119. Findings include: Review of infection control tracking for May 2024 revealed there were 32 antimicrobial (antibiotic and antifungal) treatments tracked for the month. The treatments were prescribed from a variety of sources that include from the hospital upon admission, emergency room prescribers, hospice prescribers, and the facility's prescribers. Of the antimicrobial treatments tracked in May 2024, 21 were prescribed by the facility's prescribers. Of the antimicrobial treatments prescribed by the facility's prescribers in May 2024, nine did not meet criteria for use and the antimicrobial was not discontinued. Review of infection control tracking for June 2024 revealed there were 25 total antimicrobial treatments tracked for the month. The treatments were prescribed from a variety of sources that include from the hospital upon admission, emergency room prescribers, hospice prescribers, and the facility's prescribers. Of the antimicrobial treatments tracked in June 2024, 13 were prescribed by the facility's prescribers. Of the antimicrobial treatments prescribed by the facility's prescribers in June 2024, 11 did not meet criteria for use and antimicrobial was not discontinued. Interview on 07/018/24 at 01:00 PM with Assistant Director of Nursing (ADON) #427 confirmed facility used McGeer's criteria to determine the existence of an infection and need for antimicrobial treatment. ADON #427 confirmed 11 residents did not meet the criteria for treatment in June 2024 and nine did not meet the criteria for antimicrobial treatment in May 2024, but antimicrobial treatments were not discontinued. ADON #427 confirmed the facility did not do an antibiotic timeout within 48 to 72 hours of initiation of the antibiotics to review for appropriateness. Review of the antibiotic stewardship policy dated 04/03/17, and revised 12/05/23, revealed the Medical Director oversees adherence to antibiotic prescribing practices, and reviews antibiotic use data and ensures best practices are followed. The policy revealed the facility uses the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) surveillance definitions, updated McGeer criteria, or other surveillance definitions to define infections and the Loeb Minimum Criteria may be used to determine whether to treat an infection with antibiotics. The policy further revealed that nursing will conduct an antibiotic timeout within 48 to 72 hours of antibiotic therapy to review laboratory results and consult with the practitioner to determine if the antibiotic is to continue or if adjustments need to be made based on findings.

Based on staff interview and record review, the facility failed to ensure Notice of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) forms contained all the necessary information. This affected one (#65) of three residents reviewed for beneficiary notices. The facility census was 119. Findings include: Review of Resident #65's medical record revealed an admitted [DATE]. Medical diagnoses included cerebrovascular accident (stroke), dementia, type II diabetes mellitus with diabetic neuropathy and a history of falls. Review of the Notice of Medicare Non-Coverage (NOMNC) provided to Resident #65's representative, dated 02/19/24, revealed the resident's skilled services would be ending on 02/21/24. The NOMNC did not list what specific type of skilled service would be ending. Review of the SNF ABN provided to Resident #65's representative, dated 02/19/24, revealed the resident's skilled services were being discontinued as the resident no longer required skilled services. The noticed contained no specific information as to what skilled service was being discontinued, and what specific cost the resident would incur if they desired for skilled services to continue. The cost section of the notice was labeled for the semi-private room and board rate of $304 per day. Interview on 07/18/24 at 9:25 A.M. with Director of Social Services and Admissions #605 confirmed the NOMNC and SNF ABN forms were completed incorrectly for Resident #65. The NOMNC did not contained the specific skilled service that was ending. The SNF ABN form contained only the facility's semi-private room and board rate and contained no details on what skilled services was ending, and what the cost would be for the resident to continue receiving skilled services.

Based on observation, medical record review, and staff interview, the facility failed to implement a splinting program to prevent further decrease in range of motion (ROM). This affected one (#23) of one resident reviewed for ROM. The facility census was 119. Findings include: Review of the medical record for Resident #23 revealed and admitted [DATE]. Diagnoses include aphasia, metabolic encephalopathy, contracture of the muscle of multiple sites, unspecified epilepticus, and contracture the right hand. Review of an annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 had severe cognitive impairment and was fully dependent on staff for toileting, eating, and transferring. Review of a therapy note dated 11/30/23 revealed Resident #23 was to have a rolled splint applied to the right hand and a resting splint should be used for the left hand to promote digit extension. The therapy note revealed pictures were printed and instructions were provided for staff. Review of nurse aide documentation revealed Resident #23 was to wear bilateral hand splints one at a time for two hours each alternating for eight hours upon waking. Further review of July 2024 splint nurse aide task documentation for Resident #23 revealed splints were applied on the resident's hands on 07/02/24, 07/04/24, 07/05/24, 07/08/24, 07/09/24. 07/11/24, and 07/12/24. Resident #23 did not have splints applied on 07/01/24, 07/03/24, 07/06/24, 07/07/24, 07/10/24, 07/13/24, 07/14/24, 07/15/24, and 07/16/24. Observation on 07/15/24 at 9:12 A.M., 07/16/24 at 1:34 P.M., 07/17/24 at 9:57 A.M., 07/17/24 at 2:30 P.M., 07/17/24 at 4:26 P.M., and 07/18/24 at 8:46 A.M. of Resident #23 revealed splints were not in place on the left or the right hand. Interview on 07/17/24 at 2:42 P.M. with State tested Nurse Aide (STNA) #400 confirmed splints were not on either of Resident #23's hands. STNA #400 stated Resident #23 had an order to use blocks with the resident's hands at one time but thought they did away with using blocks two months ago and was not aware of any interventions currently being used. Interview on 07/18/24 at 8:48 A.M. with Licensed Practical Nurse (LPN) #517 confirmed Resident #23 should be wearing splints to her hands but splints were not in place.

Based on observation, staff interview, medical record review, policy review, and review of facility incident reports, the facility failed to ensure fall interventions were appropriate and resident-centered, and failed to ensure residents with Wander-guards had current physician orders for the security devices. This affected two (#65 and #45) of six residents reviewed for accidents. The facility census was 119. Findings include: 1. Review of Resident #65's medical record revealed an admitted [DATE]. Medical diagnoses included cerebrovascular accident (stroke), dementia, type II diabetes mellitus with diabetic neuropathy, and a history of falls Review of Resident #65's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was assessed with severely impaired cognition. The resident had no recorded behaviors or rejection of care. The resident was identified to have two or more falls without injury and one fall with a minor injury since the prior assessment. Resident #65 was required supervision with eating, substantial/maximum assistance with activities of daily living, and required partial/moderate assistance with mobility and transfers. Review of Resident #65's plan of care dated [DATE] revealed the resident had potential for falls related to a new environment and a decline in condition. Interventions implemented included to encourage and assist with wearing non-skid footwear at all times, monitor and notify the nurse of confusion and anxiety, place frequently used items within reach, and to utilize a personal sensor alarm to bed and chair per family request to assist with safety and fall prevention. Review of Resident #65's medical record revealed she sustained falls on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Review of Resident #65's fall risk assessment, dated [DATE], revealed the resident was identified to be at moderate risk for falls. Review of the facility-initiated incident reports for Resident #65 revealed on [DATE] Resident #65 sustained a fall from the wheelchair while seated in a common area near the nurse's station. The report indicated the resident was alert only to person and place and had impaired memory. The report described Resident #65 as forgetful and unable to remember that she cannot walk. A summary note of the fall, dated [DATE], revealed the intervention for Resident #65's fall dated [DATE] was to re-educate the resident on asking for assistance with transfers. Review of an incident report dated [DATE] revealed Resident #65 sustained a fall after she was observed on the bathroom floor. The report indicated the resident was oriented to person and place. The report recorded Resident #65 as being confused and with impaired memory. A summary note of the fall, dated [DATE], revealed the intervention for Resident #65's fall dated [DATE] was to re-educate the resident against self-transfers. Review of the incident report dated [DATE] revealed Resident #65 sustained a fall and was observed on the floor with the alarm sounding. The report indicated the resident was alert and non-compliant. A summary note of the fall, dated [DATE], revealed the resident was alert to person and place. The note indicated the resident had poor safety awareness and the listed intervention for the fall on [DATE] was to re-educate the resident on call light usage for assistance. Review of the incident report dated [DATE] revealed Resident #65 sustained a fall in her room. The report indicated Resident #65 was oriented only to person, was confused, and had impaired memory. A summary note of the fall, dated [DATE], revealed the resident was alert and oriented to person and place with poor safety awareness. The listed intervention for the fall dated [DATE] was listed as re-educating the resident and a therapy screening was requested. Review of the incident report dated [DATE] revealed Resident #65 sustained a fall in her room. Resident #65 was listed as oriented only to person, with confusion, and had impaired memory. A summary note of the fall, dated [DATE], revealed the listed intervention for the [DATE] fall was listed to continue to re-educate the resident. Review of the incident report dated [DATE] revealed Resident #65 sustained a fall in her room. The resident was listed as only oriented to person, with confusion, and had impaired memory. A summary note of the fall, dated [DATE], revealed a room change was completed to move Resident #65 closer to the nurse's station. Review of the incident report dated [DATE] revealed Resident #65 sustained a fall in her room. The resident was attempting to re-arrange furniture in her room and fell . The resident was listed as only oriented to person, with confusion, and had impaired memory. There was no included summary note and no listed intervention to prevent further occurrences. An observation on [DATE] at 12:50 P.M. revealed Resident #65 was seated in her wheelchair in the common area. The resident had a personal alarm to her wheelchair in place and in the on position. An interview was attempted with Resident #65 and was unsuccessful due to the resident's cognition. Interview on [DATE] at 1:16 P.M. with Assistant Director of Nursing (ADON) #427 stated she does not attend the weekly fall meeting, but other members of nursing leadership attend and review falls to ensure appropriate interventions were in place. ADON #427 confirmed it was the facility's practice to implement interventions after instances of falls. Interview on [DATE] at 9:05 A.M. with Staff Development Nurse #478 revealed she oversaw and tracked falls at the facility. Staff Development Nurse #478 stated falls are reviewed weekly with the fall committee, and interventions are placed following instances of fall. Interview on [DATE] at 9:05 A.M. with the Director of Nursing (DON) verified Resident #65 was severely cognitively impaired. The DON verified the fall interventions placed following instances the resident's falls of education and re-education were inappropriate and ineffective due to the resident's cognition. Review of the fall policy dated [DATE] revealed the use of specific interventions to try and reduce a resident's risks from hazards in the environment. The process includes documenting interventions and ensuring the interventions are put in place. 2. Review of Resident #45's medical record identified admission to the facility occurred on [DATE] with medical diagnosis including dementia, weakness, and pneumonia. Review of an elopement risk assessment dated [DATE] revealed Resident #45 was identified by the facility to be a moderate risk for elopement. The record identified no physician orders for a Wander-guard. Resident #45's most recent admission MDS assessment dated [DATE] revealed the resident was moderately cognitively impaired. Observation of Resident #45 on [DATE] at 7:16 A.M. and [DATE] at 12:29 P. M. revealed the resident was observed with the Wander-guard device on her right ankle. Interview with Registered Nurse (RN) #500 on [DATE] at 8:34 A.M. confirmed Resident #45 had a Wander-guard on her right ankle and had physician's order for the device. Review of the Wander Management policy, updated [DATE], identified the purpose was to establish a means of prevention for elopement. The policy revealed a wander system equipped with door alarms is in place to alert staff to a resident leaving the facility unassisted. In the event the alarm system fails and or a resident is able to circumvent the system and their location cannot be determined, the facility shall take immediate action to locate the resident. The wander system bracelets will be checked each shift to ensure they are still in working order and not expired. The policy identified an assessment of residents will occur upon admission, after changes in condition, and at regular intervals thereafter. The nursing and social services departments will identify residents at risk for wandering and seek physician orders for security alarm ankle bracelets. The policy identified the process if a resident is determined to be at risk for elopement and an order will be obtained for a wander management bracelet to to applied. 34298 16453

Based on observation, staff and resident interview, medical record review, and policy review, the facility failed to ensure residents who required non-invasive mechanical ventilation through the use of a continuous positive airway pressure (CPAP) machine had a physician order in place with specified settings for the machine. This affected two (#09 and #59) of two residents reviewed for respiratory care. The facility census was 119. Findings include: 1. Review of Resident #09's medical record revealed an admitted [DATE]. Medical diagnoses included asthma, chronic obstructive pulmonary disease (COPD), and morbid obesity. Review of Resident #09's Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed the resident had severely impaired cognition and had no recorded behaviors or rejection of care. Review of Resident #09's physician order dated 01/04/23 revealed the resident was to have a CPAP machine that was to be applied per home settings nightly at bedtime and as needed. The order did not include detailed settings. Review of Resident #09's treatment administration record for April, May, and July 2024 through 07/17/24 revealed the resident was recorded to have used the CPAP on a nightly basis. Observation on 07/16/24 at 6:42 A.M. revealed Resident #09 was lying in bed. The resident had a facial mask in place and was connected to her CPAP machine. There were no clearly visible settings on the machine. Interview on 07/16/24 at 6:46 A.M. with Licensed Practical Nurse (LPN) #474 revealed the facility had on-site respiratory therapists who would clarify any orders and program equipment to the ordered settings. LPN #474 confirmed the staff nurses do not set or program respiratory equipment. LPN #474 verified she was unsure what the resident's ordered CPAP settings were, but stated she could check the orders. LPN #474 checked the residents orders and confirmed the order only specified CPAP per home settings. LPN #474 confirmed she had no way to verify if the CPAP was on the correct setting. Interview on 07/17/24 at 6:41 A.M. with Registered Nurse (RN) Supervisor #496 revealed residents with CPAP machines were supposed to have orders and settings in their respective physician's orders. RN Supervisor #496 explained the respiratory therapy department assisted with clarifying respiratory-related orders. Interview on 07/17/24 at 6:51 A.M. with Respiratory Therapist (RT) #575 revealed the respiratory therapy department assisted in clarifying respiratory-related orders if needed. RT #575 confirmed settings should be in the provider's orders for all respiratory devices, including CPAP machines. Interview on 07/18/24 at 6:41 A.M. with the Director of Nursing (DON) confirmed Resident #09's CPAP order did not contain settings. 2. Review of Resident #59's medical record identified admission to the facility occurred on 08/31/20 with medical diagnosis including sleep apnea, heart failure, anxiety, and bipolar disorder. Review of Resident #59's physician orders for July 2024 identified no evidence of any CPAP orders. Observation of Resident #59 occurred on 07/16/24 at 8:57 A.M. Resident #59 was in bed and was observed to have his CPAP machine on and running. Interview with Resident #59 on 07/16/24 at 12:49 P.M. confirmed he has been using the CPAP machine for a long time and someone came in weekly to service the machine. Interview with the Director of Nursing (DON) on 07/17/24 at 1:55 P.M. confirmed Resident #59 did not have any physician orders or evidence of tubing changes in his medical record, even though the tubing is dated as being changed. The DON confirmed the facility policy did contain the need for physician orders and documented servicing of the CPAP machine. Review of the facility noninvasive ventilation (CPAP) policy dated 06/12/23 revealed it was the policy of the facility to provide noninvasive ventilation as per physician's orders and current standards of practice. The facility will obtain an order for the use of the CPAP and settings from the practitioner. Staff are to document the use of the machine, resident tolerance, and any skin respiratory or other changes and responses. 16453

Based on medical record review, resident interview, and staff interview, the facility failed to provide dental care in a timely manner. This affected one (#28) of one residents reviewed for dental care. The facility census was 119. Findings include: Review of the medical record revealed Resident #28 was admitted on [DATE] with diagnoses that included type II diabetes, anxiety, and dementia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 was cognitively intact. Review of a dental note dated 03/15/24 revealed Resident #28 had the potential need for a consultation with an oral maxillofacial surgeon. Resident #28 potentially had extractions that were surgical in nature. Resident #28 had ankylosed (fusion between tooth/teeth and underlying bony support tissues) teeth that would need to be surgically removed by an oral surgeon. Resident #28 was ordered Peridex (used to treat gum inflammation) twice a day for seven days and amoxicillin (antibiotic) 500 milligrams every six hours. A health status note dated 03/15/24 at 2:30 P.M. revealed Resident #28 was seen by the facility dentist for a tooth extraction. The dentist was unable to pull Resident #28's tooth and was to be referred to an oral surgeon. Review of a dental note dated 06/17/24 revealed the dentist was not present and Resident #28 was seen by the dental hygienist for dental prophylaxes and topical fluoride. Resident #28 had issues with two teeth which were mobile and had a treatment for one of them to be removed. Interview on 07/16/24 at 9:00 A.M. with Resident #28 stated the resident needed to see the dentist because of a loose tooth. Interview on 07/18/24 at 9:32 A.M. with the Director of Nursing (DON) revealed there had been communication with an oral surgeon, but the oral surgeon could not pull Resident #28's tooth until 2025. The DON verified there was no documentation of the oral surgeon being contacted.

Based on observation, staff interview, medical record review, and policy review, the facility failed to use the proper cleaning chemicals were utilized in a resident room with isolation precautions. This affected one (#365) of one residents in contact isolation. The facility census was 119. Findings include: Review of the medical record revealed Resident #365 was admitted on [DATE] with diagnoses that included cellulitis of the left lower leg, Clostridium difficile (C. diff), and dementia. Review of the plan of care dated 07/15/24 revealed Resident #365 had an infection and had the potential for complications related to infection and the treatment of infection. Resident #365 was on the antibiotic vancomycin for C. diff until 07/21/24. Interventions included to administer medications as ordered and use the appropriate precautions. Observation on 07/16/24 at 12:47 P.M. revealed Resident #365 was sitting on the side of the bed and Housekeeper #556 was mopping the floor in Resident #365's room. Interview on 07/16/24 at 12:49 P.M. with Housekeeper #557 revealed the mop water had chemicals in it filled the mop bucket with the chemicals located on the wall in the housekeeping room. Housekeeper #557 stated she thought the chemicals would kill C. diff bacteria because the chemical killed everything. Interview with Housekeeping and Laundry Manager (HLM) #447 on 07/17/24 at 12:26 P.M. revealed housekeepers were aware of why residents were on contact isolation precautions so the proper chemicals could be used to clean the room. Observation on 07/17/24 at 12:29 P.M. of chemicals located on the wall in the housekeeping room revealed the chemical was called BNC-15 and was a multi-purpose cleaner. Review of the label for BNC-15 revealed it was a one-step disinfectant, cleaner, sanitizer, fungicide, mildewstat, and virucide. HLM #447 verified BNC-15 did not list it was effective in killing C. diff bacteria, and verified another chemical was to be used if contact isolation was due to C. diff. Review of the policy and procedure for C. diff revised on 03/14/17 revealed the disinfectant must be a environmental protection agency (EPA) registered, hypochlorite-based (bleach based), and directions will be followed as per label for drying and kill time. Review of the policy and procedure for daily cleaning of isolation rooms revised on 02/20/19 revealed housekeeping will use approved environmental cleaners and follow directions provided by the manufacturer. All C. diff rooms will be cleaned with bleach-based products.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, medical record review, hospital documentation review, resident and staff interview, review of a personnel file, review of a disciplinary action document, review of an investigation, policy review, and review of facility initiated corrective action, the facility failed to ensure appropriate care and assistance was provided to prevent a resident fall. This resulted in actual harm when Resident #104 was transferred by a mechanical (Hoyer) lift using only one staff member to assist, and subsequently fell , causing a facial laceration requiring sutures and a fractured right leg which required hospitalization and surgical intervention. This affected one (#104) of three residents reviewed for falls. The facility census was 113. Findings include: Review of Resident #104's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including but not limited to diabetes mellitus, acute kidney failure, and multiple sclerosis. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 09/28/23, revealed Resident #104 was assessed as cognitively intact, and was dependent on two staff members for transfers. Review of the plan of care, dated 11/07/21, revealed Resident #104 had a potential for falls related to chronic disease process with an intervention to include the use of a mechanical (Hoyer) lift with two staff members for all transfers. Review of a nursing progress note dated 11/19/23 at 3:00 P.M. revealed Resident #104 fell during a transfer and sustained an injury to his head and had complaints of right hip pain. Resident #104 was transferred to the hospital via emergency medical services (EMS), and Resident #104's family and doctor were notified. Review of an incident investigation dated 11/19/23 revealed State tested Nurse Aide (STNA) # 207 transferred Resident #104 via Hoyer lift by herself and the resident fell from the lift. Resident #104 was transferred to the hospital via EMS for evaluation due to a head injury and complaints of right hip pain. Review of a written statement from STNA #207 revealed on 11/19/23 she took Resident #104 back to his room to sit in his recliner. STNA #207 admitted to using the Hoyer lift without another staff member present to assist in the transfer. STNA #207 indicated she made sure the mechanical lift transfer pad was strapped properly, and during the transfer the lift pad strap fell off the Hoyer lift and Resident #104 fell to the floor. STNA #207 immediately called for Licensed Practical Nurse (LPN) #210, and LPN #210 along with STNA #211 and STNA #212 came to Resident #104's room. STNA #207 indicated she did not mean for Resident #104 to fall and was trying to keep Resident #104 from disturbing other residents. Review of a hospital document revealed Resident #104 was admitted to the hospital on 11/19/23 following a fall in the nursing home. Resident #104 was found to have a closed fracture of the right femoral neck, right periorbital ecchymosis (bruising around the right eye), and a right eyebrow laceration with sutures placed on 11/19/23. On 11/20/23, Resident #104 was taken to the operating room for a closed reduction with intramedullary rod fixation of the right subtrochanteric femur fracture. Resident #104 was stabilized and returned to the nursing home on 11/24/23. Observation and interview on 11/27/23 at 10:34 A.M. with Resident #104 revealed Resident #104 had several stitches over his right eye and his face was bruised but did not appear to be in pain. Resident #104 stated an STNA was not doing her job correctly when he fell . Resident #104 stated he was lifted with the Hoyer lift and then fell to the floor. Resident #104 stated his fall from the Hoyer lift on 11/19/23 was the only time there was only one staff member to operate the lift, and verified there was usually always two staff members to assist with his transfers. Resident #104 stated he liked the facility. A telephone interview on 11/27/23 at 12:00 P.M. with LPN #206 stated on 11/19/23 around 2:00 P.M., STNA #207 was very upset and adamant about LPN #206 coming to Resident #104's room. LPN #206 stated STNA #207 was crying and was hard to understand. LPN #206 stated upon arrival to Resident #104's room, the resident was laying on the floor with blood noted and the resident was in pain. A telephone interview on 11/27/23 at 12:16 P.M. with Registered Nurse (RN) #208 stated he was on another unit, when he was asked to go to Resident #104's room. When RN #208 got to the room, there were two nurses and two STNAs already in the room. RN #208 stated Resident #104 was alert and oriented but in pain, and STNA #207 was crying and really upset. RN #208 stated he pulled STNA #207 from the floor and asked her to calm down to write a statement. RN #208 stated STNA #207 indicated she did not want Resident #104 to disturb the other residents. A telephone interview on 11/27/23 at 2:04 P.M. with LPN #210 stated she was sitting at the desk when STNA #207 ran up the hall and stated Resident #104 was on the floor. LPN #210 stated STNA #207 was really upset and crying. LPN #210 stated she told STNA #207 to go get the other nurse (LPN #206), and told STNA #211 and STNA #212, who were at the nurses' desk, to go to Resident #104's room. LPN #210 stated she found Resident #104 lying on the floor in his room with some blood noted and he was in pain. LPN #210 stated she did not know why STNA #207 would have transferred Resident #104 using the Hoyer lift by herself, and stated there were enough staff members working to safely transfer the resident and there were no other problems that day. Review of STNA #207's personnel file revealed on 09/14/22, STNA #207 was provided an in-service on mechanical lift safety guidelines which included there must be two people assisting with mechanical lift transfers. Review of a disciplinary action document dated 11/20/23 revealed on 11/19/23 at approximately 1:30 P.M., STNA #207 took a resident (#104) to his room to lay him down in a recliner after lunch. STNA #207 reported she utilized the Hoyer lift alone and the lift pad sling came loose from the Hoyer lift causing the resident to fall to the floor resulting in major injuries. STNA #207 was terminated from employment on 11/20/23. Review of the facility policy titled, The Good [NAME] Transfer Policy, with an implementation date of 12/15/22, revealed two staff members must be utilized when transferring residents with a mechanical lift. The deficient practice was corrected on 11/24/23 when the facility implemented the following corrective actions: On 11/19/23 at 1:30 P.M., STNA #207 was caring for Resident #104, who tends to yell out, so STNA #207 decided to bring him back to his room after eating lunch and transfer him to his recliner. STNA #207 elected to transfer Resident #104 by herself in a Hoyer lift even though the facility had adequate staffing available to assist. STNA #207 ran to get LPN #210, STNA #211, and STNA #212 to Resident #104's room. STNA #207 indicated the Hoyer lift pad strap by the right side of Resident #104's head popped off the bar and the resident then slid out onto his right side to the floor. LPN #210 called EMS as soon as she saw Resident #104 on the floor with a head laceration. On 11/19/23 at 1:33 P.M., EMS arrived at the facility and LPN #206 performed a visual inspection of the lift pad that was under Resident #104, and found the straps were completely intact with no tears or fraying. On 11/19/23 at 1:55 P.M., RN #208 performed a visual inspection of the Hoyer lift in use, and discovered the lift was in good working condition with no defects. On 11/19/23 at 1:59 P.M., RN #208 informed LPN Staff Development #209 of the incident with Resident #104 and indicated once STNA #207 completed a written statement regarding the incident and STNA #207 would be sent home. On 11/19/23 at 2:11 P.M., LPN Staff Development #209 notified the DON of the incident with injury to Resident 104 and was informed STNA #207 would be going home once her written statement was completed. On 11/19/23 at 2:30 P.M., the DON called RN #208 to review the incident and to verify that STNA #207 was going home once her statement was completed. On 11/19/23 at 2:35 P.M., RN #208 called Resident #104's representative and informed him of the fall with injury. On 11/19/23 at 2:37 P.M., STNA #207 finished her written statement while being supervised by RN #208 then clocked out and went home. On 11/19/23 at 3:17 P.M., the DON emailed an education and followed up with a phone call to RN #208 to immediately in-service staff on proper transfer via Hoyer lift. All staff were educated by 11/24/23. On 11/19/23 at 6:17 P.M., RN #208 informed the DON that Resident #104 was admitted to the hospital. On 11/19/23, STNA #200 and STNA #201 checked Hoyer lift pads to ensure there were no frays, rips, or tears with no concerns noted. A second check of the Hoyer lift pads was completed by STNA #204 and STNA #205 on 11/20/23 with no concerns. Additional audits of all Hoyer lift pads on 11/21/23, 11/22/23, 11/25/23, and 11/26/23 revealed no concerns. On the morning of 11/20/23, Maintenance Director #216 did a visual inspection of all facility Hoyer lifts and hanger bars and found them to be intact, without defect, and functioning properly. Audits will continue weekly for four weeks and then monthly for three more months to ensure compliance. On 11/20/23 at 2:45 P.M., the DON and Assistant Director of Nursing (ADON) #213 met with STNA #207, and STNA #207 admitted to knowing the facility's policy and practice was to perform all mechanical lifts with two staff members. STNA #207 indicated although staffing was good, she attempted to perform Resident #104's transfer by herself to be efficient. STNA #207 was terminated from her position on 11/20/23. On 11/20/23, resident care plans were reviewed to ensure residents who required a mechanical lift for transfers had appropriate interventions in place. All care plans were reviewed and updated by 11/22/23. On 11/20/23, Hoyer lift pads were labeled and tracked by Laundry Aide #217 with each time they were laundered and were inspected and logged. Any Hoyer pad with fraying or tears were immediately taken out of circulation and were destroyed. On 11/20/23 at 9:00 A.M., a Quality Assurance and Performance Improvement (QAPI) meeting was held with the DON, ADON #213, the Administrator, and LPN Staff Development #209 to discuss Resident #104's fall. The Medical Director was in the facility at 4:00 P.M. and was updated on the facility's action plan. On 11/20/23, Hoyer lift transfers were observed by LPN #214 with no concerns. LPN #214 made additional observations of Hoyer lift transfers on 11/21/23 and 11/24/23 with no concerns observed. LPN #214 and ADON #213 will continue to observe a minimum of two mechanical lift transfers each week for four weeks then twice monthly for two months to ensure compliance. Interviews on 11/27/23 from 6:40 A.M. through 3:30 P.M. with STNA #200, STNA #201, STNA #202, STNA #204, and STNA #205 all verified they were educated on the need for two staff members for all Hoyer lift transfer and confirmed appropriate knowledge of the facility's mechanical lift policy and procedure. All STNAs verified they check Hoyer lift pads for defects before use and indicated nurses will assist with Hoyer lift transfers when necessary. This deficiency represents non-compliance investigated under Complaint Number OH00148536.

Based on observations, staff interviews, and policy review, the facility failed to remove expired medications from the medications carts and medication storage rooms. This affected three of six medication carts and two of three medication storage rooms. This had the potential to affect all 92 residents residing in the facility. Findings include: Observation of Windsor medication cart on 03/01/22 at 7:55 A.M. revealed a bottle of CoQ 10 was found with an expiration date of 01/2022 and a bottle of aspirin 325 milligrams (mg) was located in the cart with an expiration date of 11/2021. Observation of the Windsor [NAME] Hall medication room on 03/01/22 at 8:22 A.M. revealed the following medications expired: [MEDICATION(S)] (sleep aid) 3.0 mg expired 10/2021, Loperamide (anti-diarrhea) 2.0 mg expired 11/2021, B6 vitamins 100 mg expired 11/2021, Geri Dry [MEDICATION(S)] (antihistamine) expired 11/2021, and cetirizine [MEDICATION(S)] (antihistamine) 10 mg which had expired on 07/2021. Observation of the West hall cart on 03/01/22 at 8:35 A.M. revealed two bottles of Vitamin B12 500 mg had expired in 03/2021 and two bottles of simethocone (gas relief) 125 mg had expired on 06/2021. Observation of the medication room on the West hall on 03/01/22 at 8:43 A.M. revealed a bottle of Vitamin B12 500 mg was found to be expired in 03/2021 and a bottle of Geri Dry Allergy Relief had expired in 11/2021. Interview with Licensed Practical Nurses #134 and #192 and Registered Nurse #110 on 03/01/22 between 7:58 A.M. and 8:46 A.M. verified the medications had expired and should have been removed from the medication carts and medication storage rooms. These medications were stock and used by all residents who were prescribed them. Review of the facility's policy titled Medication Storage, dated May 2017, revealed it was the policy of the facility to ensure all medications house on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendation and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security.

Based on record review, staff interviews, resident interviews, and review of the facility's policy, the facility failed to ensure the residents were assisted with showers routinely and timely as scheduled. This affected two (Residents #27 and #65) of three residents reviewed for bathing. The facility identified all 92 residents required assistance or were dependent on staff for assistance with bathing. The facility census was 92. Findings include: 1. Review of Resident #27's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #27's quarterly Minimum Data Set (MDS) assessment, dated 12/21/21, revealed the resident had a high cognitive function. Resident #27 required a one person physical assist with hygiene and was a total dependence on staff for bathing. Review of Resident #27's shower schedule revealed the resident was to have a bath every Monday and Friday. Review of Resident #27's shower documentation electronic records revealed she received a shower/bath on Wednesday 02/02/22, Friday 02/04/22, Friday 02/11/22, Saturday 02/12/22, Friday 02/18/22, Saturday 02/19/22, Monday 02/21/22, and Saturday 02/26/22. Interview with Resident #27 on 02/28/22 at 10:03 A.M. revealed the resident was not receiving timely showers. She stated she was given a shower once weekly, but had gone two weeks without a shower or bath. Interview with the Assistant Director of Nursing (ADON) #500 on 03/03/22 at 10:14 A.M. verified the facility failed to administer Resident #27's showers timely. The ADON verified Resident #27 went seven days without a shower or bath between 02/04/22 and 02/11/22 and six days between 02/12/22 and 02/18/22. 2. Review of Resident #65's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #65's quarterly MDS assessment, dated 01/24/22, revealed the resident had a moderate impairment in cognitive function. Resident #65 required an extensive assistance two person assist for personal hygiene and bathing. Review of Resident #65's most recent care plan revealed she resident required one staff participation with bathing. Review of Resident #65's shower schedule revealed the resident was to have a bath every Wednesday and Friday. Review of Resident #65's shower documentation electronic records revealed she received a shower/bath on Tuesday 02/08/22, Monday 02/14/22, Wednesday 02/16/22, and Saturday 02/19/22. The resident was documented as refusing a bath/shower on Tuesday 02/15/22 and Friday 02/25/22. Interview with Resident #65 on 02/28/22 at 10:47 A.M. revealed her showers/bathes were not given timely and she may go a couple of weeks without a shower. Interview with the Assistant Director of Nursing (ADON) #500 on 03/03/22 at 10:14 A.M. verified the facility failed to administer Resident #65's timely. The ADON verified Resident #65 went without a shower for six days between 02/08/22 and 02/14/22 and had no shower from 02/19/22 through 03/01/22. The ADON also stated the nursing staff failed to document any refusals or why the showers had not been completed. Review of the facility's policy titled Resident Shower/Bathing revealed residents will be provided showers as per request or as per facility schedule protocols and based upon resident safety. Resident bath schedules will be posted at each nurses station. The staff must document the resident bath acceptance in Point Click Care or alternative record if needed. Report any declined baths to the charge nurse.

Based on review of the facility's policy, observation, record review and resident and staff interview, the facility failed to provide adequate activities for Resident #9. This affected one (Resident #9) of two residents reviewed for activities. The facility census was 92. Findings include: Review of Resident #9's medical record revealed an initial admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual Minimum Data Set (MDS) 3.0 assessment, dated 11/24/21, revealed Resident #9 had intact cognition. Resident #9 was totally dependent on staff for bed mobility, transfers, toileting, and personal hygiene. Resident #9 considered doing things with groups of people to be somewhat important and participating in her favorite activities to be very important. Review of the plan of care, dated 10/16/21, revealed Resident #9 had the potential for alteration in scheduled/self-initiated events. Interventions included encouraging the resident to participate in activities, offering invites and encouragement, and providing assistance to and from activities as needed. Resident #9 was dependent on staff for activities, cognitive stimulation, and social interaction related to disease process, [CONDITION(S)], immobility, and physical limitations. Interventions included assuring activities the resident was attending were compatible with the resident's physical and mental capabilities, compatible with known interests and preferences, and the resident would be provided with a program of activities that were of interest and empowered the resident. Review of the activities progress notes dated 08/02/21 at 10:07 A.M. revealed Resident #9 continued to enjoy manicures, group activities, one-on-one visits, listening to music on her phone, and going outside on walks. No activities progress notes were documented from 09/21/21 through 03/03/22 regarding the resident attending activities, declining activities, or an activities progress note update. Review of the activity logs for December 2021, January 2022, and February 2022 revealed one-on-one visits were documented as provided to the resident on 02/01/22, 02/07/22, 02/08/22, 02/09/22, 02/11/22, 02/14/22, and 02/16/22. Activities cart was documented for resident participation on 02/03/22. No other activities were documented for the resident within this time period. Interview on 03/03/22 at 10:42 A.M. with the Assistant Director of Nursing (ADON) verified there were no additional activities progress notes for Resident #9 from 09/21/21 through 03/03/22. Observations on 02/28/22 at 10:41 A.M., on 03/01/22 at 11:16 A.M., on 03/02/22 at 1:51 P.M., and on 03/03/22 at 8:47 A.M. revealed Resident #9 was sitting upright in her motorized wheelchair, with the television turned on. Interview on 02/28/22 at 10:41 A.M. with Resident #9 revealed the resident enjoyed participating in activities but the facility had not been having any activities for several months. Review of the faciliy's activities calendars for the Rehabilitation Unit dated January 2022, February 2022, and March 2022 revealed there were no scheduled group activities for January 2022 or February 2022. Activities on each calendar included self-directed activities and the March 2022 calendar included unscheduled staff visits to resident rooms. Interview on 03/02/22 at 2:36 P.M. with Activities Director #204 verified there were no scheduled activities or group activities for January 2022, February 2022, and March 2022. Activities Director #204 stated this was due to activities personnel being trained as State tested Nursing Assistants (STNA) and often getting pulled to work as STNAs. Activities Director #204 reported there was a full-time activities staff member who worked the rehabilitation unit but they had not worked at the facility since August or September of 2021. Review of the facility's policy titled Resident Activities, revised January 2002, revealed the activities department would provide activities designed to meet the specific needs and/or interests of all residents on each unit. Review of the facility's policy titled Activities Department Documentation revealed each resident's medical record would contain a quarterly activities update progress note.