Every finding on record at The Heights on Valley Ranch

Number of residents sampled: Number of residents cited: Based on observation, interview and record review the facility failed to ensure that residents who are incontinent of urine and bowel is identified, assessed and provided appropriate treatment and services to achieve or maintain as much normal bladder function as possible including incontinence products for 4 of 6 (Resident #110, Resident #4, Resident #80, Resident #16 ) residents reviewed for Bowel/Bladder Incontinence, Catheter, and UTI. The facility failed to consistently provide an adequate supply of incontinent briefs and wipes for residents who required a size 3x adult brief (Resident #110 and Resident #4) and residents who required a size 5x adult brief (Resident #80 and Resident #16). This failure placed residents at risk of not having their immediate needs met, skin breakdown and infections. Findings include:Resident #110Record review of Resident #110's face sheet dated 07/30/2026 revealed she was an [AGE] year-old female who was originally admitted to the facility on [DATE] and admitted on [DATE]. Her admitting diagnoses included metabolic encephalopathy (brain dysfunction), type 2 diabetes mellitus (high blood sugar), hypertension (high blood pressure), atrial fibrillation (irregular heart beat), hyperlipidemia (high cholesterol), chronic kidney disease (kidneys cannot filter blood properly), atherosclerotic heart disease (stiffening and thickening of blood vessels in the heart), muscle weakness, and abnormalities of gait and mobility (difficulty walking). Record review of Resident #110's Quarterly MDS dated [DATE] revealed a Cognitive BIMS summary score of 12 that indicated moderate cognitive impairment. Resident #110's functional abilities revealed she was dependent on staff for toileting hygiene, shower/bathe self, lower body dressing, putting on/taking off footwear, personal hygiene and required substantial/maximal assistance for upper body dressing. Resident #110 was dependent on staff for rolling left and right, sit to lying, lying to sitting on side of bed and Resident #110 did not sit to stand, toilet transfer or walk 10 feet. Resident #110 was frequently incontinent of urinary continence and was always incontinent of bowel. Resident #110 was not on a urinary or bowel toileting program. Record review of Resident #110's care plan updated 07/10/2026 revealed a diagnosis of metabolic encephalopathy with a goal to participate in care with ADLs and required 1 staff for dressing and grooming and personal hygiene. In an interview on 07/28/2026 at 10:59 AM with Resident #110 she stated she was treated fine, but as far as the supplies she needed the facility stated they will order more. Resident #110 stated some of the CNA's did not have what she needed. Resident #110 stated the adult brief was supposed to be provided but her insurance stepped in and started providing her with adult briefs. She stated the adult briefs had started disappearing and the CNA's borrowed her adult briefs to use on other residents. Resident #110 stated that the CNA's apologized and said they would borrow the adult briefs and that they would have more adult briefs the following day, but the CNA's did not bring her adult briefs back. Resident #110 stated the CNA's went to the person who ordered the adult briefs and the CNA's were told to get what they could. Resident #110 stated the CNA's told her that they get adult briefs from other residents. Resident #110 stated it was very discouraging and when she asked the CNA's to change her, she was afraid she would not have any more adult briefs. She stated there was a time when she needed to have a diaper change and there were no adult briefs. Resident #110 stated the CNA's went and found an adult brief from someone else. Resident #110 was observed to be obese. Resident #110 stated she has had to lay a couple of hours without being clean, but it was normal because the CNA's had 15 residents to change and sometime the facility was low on staff. She stated it just bothered her when the facility did not have the adult briefs diapers and the little packages of ointment for her bottom. In an observation and interview on 07/29/2026 at 8:58 AM with Resident #110 revealed Resident #110 had 7 adult briefs in a size 3 xl. She stated that no one came for her supply of briefs last night that she knew of. In an interview on 07/29/2026 at 3:03 PM with Resident #110 she stated she was ok. Resident #110 stated she ran out of adult briefs before and the facility did not have any. Resident #110 stated the CNA took another resident's adult briefs. Resident #110 explained that her insurance paid for her adult briefs, but they take her briefs to use on other residents. Resident #110 stated one time the facility ran out of wipes and had to use wash clothes to clean her. In an interview on 7/30/26 at 10:10 am with Resident #110 she stated it made her afraid that she would have to be wet all day. She stated the CNA's had to put on a brief that was too small for her. Resident #110 stated she had to wear a size 2xl adult brief instead of a 3x adult brief. She stated it was tight and that it caused an overflow all over the bed when the briefs are too small. Resident #110 stated that it happened 2 to 3 times when they had to put a smaller adult brief on her. Resident #110 stated that the supplies do not last long. Resident #4 Record review of Resident #4's face sheet dated 07/30/2026 revealed he was a [AGE] year-old male who was originally admitted to the facility on [DATE] and admitted on [DATE]. His admitting diagnoses included infection following a procedure, intellectual disabilities, body mass index, gastro-esophageal reflux disease (stomach acid flows back into the esophagus), pain in left knee, necrotizing fasciitis (flesh eating disease), acute respiratory failure (lungs abruptly fail to maintain normal oxygen and carbon dioxide level in the blood), insomnia (difficulty falling asleep), hypertension (high blood pressure), and hyperlipidemia (high cholesterol). Record review of Resident #4's Quarterly MDS dated [DATE] revealed a BIMS Summary Score of 15 indicating intact cognitive function, meaning the individual shows normal memory, orientation, and thinking abilities. Resident #4's functional abilities revealed he was dependent on 1 staff for toileting hygiene, shower/bathe self, upper and lower body, and personal hygiene. Resident #4 was not applicable for sit to stand, toilet transfer, tub/shower transfer and walk 10 feet was not attempted due to medical condition or safety concerns. Record review of Resident #4's care plan dated 5/15/26 revealed a risk for self-care deficit, falls, skin concerns, infection, and emotional distress. Resident #4 required staff to provide ADL care as indicated, inspect skin for skin breakdown ad report to nurse, turn, and reposition every 2-3 hours or more often as needed and ensure clean and dry. In an interview on 07/30/2026 at 3:15 PM with Resident #4 he stated he used adult briefs, but sometimes the facility ran out. Resident #4 stated the CNA's borrowed adult briefs from another resident until the facility ordered more. He stated the facility never had to put a smaller adult brief on him, but sometimes they ran out of wipes. Resident #4 stated when the facility ran out of the wipes, they had to find some in another resident's room and sometimes the CNA's used towels to clean him. Resident #80Record review of Resident #80's face sheet dated 07/30/2026 revealed she was a [AGE] year-old female who was admitted on [DATE]. Her admitting diagnoses included acute chronic systolic (congestive) heart failure (heart failure due to reduced contractility of the left ventricle), type 2 diabetes with diabetic neuropathy (high blood sugar with injury to the nerves), acute respiratory failure with hypoxia (rapid impairment of gas exchange between the lungs and the blood leading to low oxygen and high carbon dioxide), morbid (severe) obesity due to excess calories, major depressive disorder, hypertension (high blood pressure), hyperlipidemia ( high cholesterol), bilateral primary osteoarthritis (degenerative joint disease affecting both knees), functional quadriplegia (profound immobility affecting all four limbs), chronic kidney disease (kidneys cannot filter the blood properly) and chronic atrial fibrillation (irregular heart beat). Record review of Resident #80's Quarterly MDS dated [DATE] revealed a BIMS Summary score of 15 indicating intact cognitive function, meaning the individual shows normal memory, orientation, and thinking abilities. Resident #80's functional abilities revealed she required supervision or touching assistance for toileting hygiene, personal hygiene, roll left and right, sit to lying, sit to stand, chair/bed to chair transfer, toilet transfer, tub/shower transfer and walking 10 feet. She required partial/moderate assistance with lower body dressing. Record review of Resident #80's care plan dated 7/10/26 revealed a self-care deficit requiring 1 staff to assist with bathing/showering care, bed mobility/turning & repositioning, dressing & grooming, and toilet transfer. The staff were to provide incontinent care every shift. In an interview on 07/30/2026 at 3:28 PM with Resident #80 she stated that her stomach had been bothering her and she was on Manjiro. She stated she has had problems when the staff did not always have her size brief. Resident #80 stated she wore a size 5x and the CNA's have used a smaller size adult brief. She stated the CNA's used a 3x and its a tighter fit. Resident #80 stated the 5x is more absorbent and it fit better. She stated the 5x was more comfortable and fit better. She stated the facility ran out of wipes and they looked around and found some. Resident #80 stated there were times when the CNA's had to use a wash rag. She stated there was an issue with the facility not having enough wipes. Resident #80 stated when she admitted to the facility they had the supplies the residents needed, but since May 2nd, the the facility had not had the supplies always available. She stated it was not every day, but it was enough that they needed to have more supplies. Resident #16Record review of Resident #16's face sheet dated 07/30/2026 revealed she was a [AGE] year-old female who was admitted on [DATE]. Her admitting diagnoses included dementia (decline in cognitive function), body mass index 45.0-49.9 adult (obese), type 2 diabetes (high blood sugar), hypertension (high blood pressure), abnormalities of gait and mobility (difficulty walking), depression, and hyperlipidemia (high cholesterol). Record review of Resident #16's Quarterly MDS dated [DATE] revealed a BIMS Summary score of 10 indicating moderate cognitive impairment. Resident #16's functional abilities revealed she was dependent on staff for toileting hygiene, lower body dressing, sit to stand, toilet transfer and walking 10 feet was not applicable. Record review of Resident #16's care plan dated 5/26/26 revealed a self-care deficit due to dementia and morbid obesity. Resident #16 required 1 staff to assist with bathing/showering, bed mobility, dressing & mobility, hygiene, toileting hygiene/Incontinent care, toilet transfer by mechanical lift with 2 staff using an x-large sling 275-500 pounds. In an interview on 07/30/2026 at 3:34 PM ,Resident #16 stated that she had not had any problem with the staff having briefs. She stated if the staff did not have enough adult briefs, then they went to someone else's room and found some. In an observation and interview on 07/29/2026 at 9:16 AM of the supply closet 1 with LVN A revealed: 1 pack of 3xl adult briefs, 4 packets of 2xl adult briefs, 3 packs of xl adult briefs, no 4x adult briefs, no 5x adult briefs, and 2 packs of wipes. LVN A stated when the CNA's need adult briefs or wipes that they ran out of they would have to go find some. LVN A acknowledged there were 2 packs of wipes, and she stated when they did not have any supplies, she called the DON. LVN A stated the facility had another supply closet by the time clock, but they do not have a key to that. LVN A stated there were residents who stated they were afraid to say they need an adult brief change. LVN A stated that some of the residents' responsible parties started supplying adult briefs because of the supply. In an interview on 07/29/2026 at 9:23 AM with CNA A she stated when the facility was low on briefs the CNA's ask central supply for what they need. In an observation and interview on 07/29/2026 at 9:28 AM with CNA B she stated the briefs that are size 5xl and 3xl were the hardest to find in the facility and they usually kept the briefs in the office. CNA B stated the CNAs try to save them when they can. CNA B stated the facility had the other size briefs most of the time. She stated that the hardest thing was the wipes and the CNA's were always searching for wipes. CNA B stated if they do not have wipes, they have to use wash clothes with soap and water to clean the residents. CNA B stated this happened very often. Observation revealed LVN A came and handed CNA B a size 5xl adult brief and it was the last brief in the package. In an interview and observation on 7/29/26 at 9:42 am, CNA B was observed going to the Medical Records office to get 3xl adult briefs. She stated if she did not have wipes, then she had to wash the resident with soap and water. She stated the problem was 3 and 5xl adult briefs. CNA B stated they have to use a 2xl adult brief on a resident that wore a 5x adult brief. In an interview on 7/29/26 at 9:46 am, CNA C stated that when she was running low on adult briefs, she told central supply, then she searched resident drawers and other hallways. She stated if she could not find what she needed she worked with what she had, even if it was a pull up or a smaller size. CNA C stated it did not happen often during the week, but on the weekend when no one was at the facility. CNA C stated when she did not have wipes, she looked through resident drawers, and she tried to keep packets on herself. She stated there was a struggle for wipes, and if she did not find any wipes, she used a washcloth with soap and water. She stated she was looking for size 3xl adult briefs today. In an interview on 7/29/26 at 9:55 am, LVN B stated when they run low on briefs, they are in the office on 300 hall. She stated she knew the code to get in the room for the weekend staff. She stated they had to call someone if there were no adult briefs. LVN B stated there were also supplies in the central supply office. Observation and interview on 7/29/26 of the Central Supply of supply room [ROOM NUMBER] revealed 4 boxes of 3xl adult briefs with 48 briefs in each. Central Supply stated she did not have any 4xl adult briefs. She stated the facility had 2 residents who used 5xl adult briefs and she had 2 packs. Observation revealed there were 8 adult briefs in each pack. The Central Supply staff stated she had a shipment coming in today, 7/29/26. She stated the CNA's knew to come to her office to get the 3xl and 5xl adult briefs. Observation revealed there were 2 packs of wipes in the supply room. She stated the CNA's already had their supply for today, 7/29/26. She stated she put out 3 cases of wipes daily with 12 packs of wipes in each case. She stated there were 68 wipes in each packet. The Central Supply staff stated on the weekends when she was not at the facility, she left supplies for the weekend supervisor, and the weekend supervisor has the key to the supply room, or the staff had to call her. She stated at night, the supply closet key was left in the office, and the staff had the key to get in. In an interview on 07/30/2026 at 9:44 AM, CNA B stated they did not normally have that many supplies. She stated the delivery truck just came yesterday, 7/29/26. CNA B stated the CNAs had to ask them for supplies and if there was none they told her that they have to wait on the supply truck. CNA B stated they made due with what they had with towels, soap and water and whatever size briefs they had. CNA B stated when the truck arrived, they changed the residents with the right supplies. In an interview on 07/30/2026 at 9:50 AM, CNA D stated she had been working at the facility for almost 8 months. CNA D stated when she first came the facility was ok, but she did not think that the facility did not have the wipes and briefs, but they had to search for them. She stated the last month they stopped the CNAs from going to get their supplies. CNA D stated they used to be able to get their own supplies themselves from the supply room, but now they were trying to get used to the new process of asking for supplies and waiting until they receive them. CNA D stated she has had to put a different size brief on a resident when they did not have the right size. She stated she has had to do this many times using different size adult briefs. She stated that they ran out of sizes 3x and 5x. She stated on her hall she had Resident #110 in a 3x, and Resident #16 and Resident #80 who wore a size 5x. CNA D stated the residents normally had to wear the 2xl briefs and sometimes they had the 3x, but not the 5x. In an interview on 07/30/2026 at 12:45 PM with Central Supply she stated that she just started working at the facility in April 2026. She stated she was bringing the 5x and 3x adult briefs to the rooms and they were gone in one day. She stated the facility came up with the idea of putting the adult briefs in the office or at the back nurses station. She stated when she was not at the facility, the weekend supervisor had the key to get the supplies. She stated she did not know it was a bad problem until yesterday. She stated the CNA's were using the whole pack of briefs in one day. She stated if the CNA's were rounding every 2 hours, then the staff needed at least 6 briefs for the day. Observation with Central Supply revealed there were only 8 briefs in one pack of 5xl adult briefs. The Central Supply staff stated she did not have any residents on the 4x adult brief. She stated she ordered supplies by the amount of cases she needed and the amount of residents. She stated she tried to over order just in case. She stated when the facility ran out she got the credit card from the Administrator and she went to buy more supplies. She stated since she had been in the position she has had to do it twice for the bariatric brief for a new gentleman that was on the hall I, that needed a size bigger than the 5x. She stated she ordered 20 cases of wipes and the CNA's did not really run out of the wipes. She stated housekeeping threw everything away when people moved out. She stated she had a backup stash of wipes, and the CNA's just had to let her know that they do not have any on the hallway. She said she never told any CNA to use a towel with soap and water. She stated the staff had already come to get their supplies for the day and observation revealed there were 2 packs left. She stated her delivery was late. She stated she did not have a list of residents with the size briefs they wore, but she knew the residents who required what size. Observation revealed xl had 12 adult briefs in each pack. She stated Resident #4 wore 3x, and 2 residents (Resident #80 and Resident #16) who wore 5x briefs (8 in a pack). She stated Resident #110 had her own briefs. She stated everyone else wore a 2x and xl. She stated orders were made every Monday and she ordered 20 cases of Wipes every Monday. In an interview on 07/30/2026 at 1:22 PM, the DON stated she had never heard of anyone being washed with a washcloth when they did not have wipes. The DON stated the facility had an abundance of supplies and the staff were wasteful at the facility. She stated the facility had adult briefs in the drawers and several packs of wipes in the rooms. She stated they order supplies and order more when the staff said something. The DON stated the company they used were doing a combo for small, medium, and large adult briefs. The DON stated she guessed there was not a big difference between a 2x and 3 x adult briefs, maybe a couple of centimeters. She stated the briefs had Velcro with the straps on the side. Record review of facility policy on Equipment, Supplies, Nurse Call System dated 2/26/22 and date revised January 2023 revealed compliance guidelines: Appropriate equipment supplies.Nurse call system, equipment and supplies needed to provide patient care and meet patients' needs should be maintained and in good repair prior to use and will be obtained or maintained from central supply or an approved vendor.

Number of residents sampled: Number of residents cited: Based on observation, interview and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 3 of 6 (Resident #110, Resident #54, and Resident #5) residents reviewed for environment. -The facility failed to provide a safe, clean, comfortable, and homelike environment as evidenced by spider webs being found in Resident #110, Resident #54, and Resident #5's room. These failures could place residents at risk of an unsafe, unsanitary, and uncomfortable living environment. Record review of Resident #110's face sheet dated 07/30/2026 revealed she was an [AGE] year-old female who was originally admitted to the facility on [DATE] and admitted on [DATE]. Her admitting diagnoses included metabolic encephalopathy (brain dysfunction), type 2 diabetes mellitus (high blood sugar), hypertension (high blood pressure), atrial fibrillation (irregular heart beat), hyperlipidemia (high cholesterol), chronic kidney disease (kidneys cannot filter blood properly), atherosclerotic heart disease (stiffening and thickening of blood vessels in the heart), muscle weakness, and abnormalities of gait and mobility (difficulty walking). In an observation and interview on 7/30/26 at 10:10 am with Resident #110 observation revealed a spider web by Resident #110's privacy curtain. Resident #110 stated spider web made her feel afraid. She stated she went out of control when she saw a spider. Further observation of Resident #110's room revealed a spider web on the top of the wall in the corner by Resident #110's bed, and observation revealed a spider at the top of the wall at front door in the corner and there was another spider web. Resident #110 stated that to her all spiders were deadly. Resident #54Record review of Resident #54's face sheet dated 07/28/2026 revealed he was a [AGE] year-old male who was originally admitted to the facility on [DATE] and admitted on [DATE]. His admitting diagnoses included hemiplegia and hemiparesis, type 2 diabetes mellitus (high blood sugar), hypertension (high blood pressure), hyperlipidemia (high cholesterol), benign prostatic hyperplasia, discitis, peripheral vascular disease, muscle weakness, and blindness right eye. In an observation on 7/28/26 at 10:21 am of Resident #54's room revealed a spider web on his curtain by the window and in the corner of the wall. Further observation revealed there was also a spider web by the bathroom wall. In an observation and interview on 7/30/26 at 10:18 am, Resident #54 stated that he could not move if a spider were to get on him. He stated that it bothered him that there were spider webs in his room. He stated that he did not know how it made him feel. Observation revealed spider webs at the door to the room above the door. Resident #5Record review of Resident #5's face sheet dated 07/30/2026 revealed he was a [AGE] year-old male who was originally admitted to the facility on [DATE] and admitted on [DATE]. His admitting diagnoses included displaced intertrochanteric fracture of right femur, nontraumatic hematoma of soft tissue, end stage renal disease, hypertension (high blood pressure), and anemia. Observation on 7/30/26 at 10:22 am in Resident #5's room revealed spider webs on the corners of the wall. Observation revealed Resident #5 was lying in bed with his eyes closed. In an interview on 7/30/26 at 10: 24 am, the House Keeping and Laundry Supervisor stated the facility had a quality-controlled inspection and it broke it down for the bathroom and living area of the resident. She stated they cleaned the blinds, overhead light, bedside tables sanitized, furniture sanitized, base boards and edges. She stated they also cleaned, toilet, sink, showers, and floor were being swept and sanitized. She stated the facility used a 5-step process. She stated they did these inspections daily and they randomly chose a room from each of the housekeeper's rooms and they check randomly down the checklist. She stated she had not selected any resident rooms yet today, 7/30/26. In an observation and interview on 07/30/2026 at 11:19 AM with CNA D she stated the object that was located in Resident #110's room looked like a spider with spider webs. In an interview on 7/30/26 at 4:25 pm with the Maintenance Director he stated the facility completed monthly pest control and if they had any issues in between that time, they would call pest control. He stated that pest control did spray for spiders, both outside the facility and the interior. He stated that spider webs were a housekeeping thing and that maintenance did not handle cleaning. The Maintenance Director stated that they had pest control to spray in every room monthly. In an interview on 07/30/2026 at 5:18 PM with the DON she stated housekeeping was responsible to make sure there were no spider webs in the residents' rooms. She stated housekeeping was supposed to clean the room but if the staff see anything they let housekeeping know. The DON stated they have the If you see something say something watch. Record review of facility policy on Physical Environment dated February 2017 and revised January 2023 revealed: Pest control-The community maintains an effective pest control program so that the community is free of pests and rodents. Other environmental conditions: The community environment is safe, functional, sanitary, and comfortable for residents, team members, and the public.

Number of residents sampled: Number of residents cited: Based on interview and record review the facility failed to ensure residents reviewed for showers who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 6 Residents (Resident #76). -The facility failed to ensure Resident #76 who was unable to carry out activities of daily living received a shower for 5 days. Failure to provide residents with showers could cause infections, poor grooming, less participation in activities and shame. Record review of Resident #76's face sheet dated 07/29/2026 revealed she was a [AGE] year-old female who was originally admitted to the facility on [DATE] and admitted on [DATE]. Her admitting diagnoses included wedge compression fracture of T9-T10 vertebra (collapse of the front portion of these thoracic vertebrae, often causing pain, limited mobility, and potential spinal instability), wedge compression fracture of first lumbar vertebra (vertebral compression fracture where the front of the vertebra collapses while the back remains intact), nonrheumatic aortic (valve) stenosis (the aortic valve narrows due to degenerative or age-related changes, restricting blood flow from the heart to the body), type 2 diabetes mellitus (high blood sugar), cardiac pacemaker (device that helps regulate the heart's rhythm), hypertension (high blood pressure), paroxysmal atrial fibrillation (irregular heart rhythm that starts suddenly and stops on its own or with treatment), acute kidney failure (kidney lose their ability to filter blood properly), anemia, morbid (severe) obesity due to excess calories, hypothyroidism (overactive thyroid), atherosclerotic heart disease (narrowed arteries due to plaque causing the reduction of blood flow to the heart), and sick sinus syndrome (slow heart beat). Record review of Resident #76's admission MDS dated [DATE] revealed a BIMS score of 15 which indicated intact cognitive function, meaning Resident #76 showed normal memory, orientation, and thinking abilities. Functional abilities revealed she was not applicable (not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury) to shower/bathe self, she was dependent on staff for oral hygiene, toileting hygiene, upper and lower body dressing, and personal hygiene. Resident #76 was not applicable for tub/shower transfer and required partial/moderate assistance for walking 10 feet. Record review of Resident 76's care plan updated 07/29/2026 revealed provide ADL care as indicated. Resident #76 required assistance with bed mobility/ turning and repositioning, dressing &grooming, ambulate x 1 person assisting, and personal hygiene she required supervision set up assistance. Record review of Resident #76's Task: Bathing for July 2026 revealed she received a bath on 7/13/26, 7/17/26, 7/20/26 and 7/22/26. Record review did not reveal a bath from 7/23-7/29/26. In an interview on 07/28/2026 at 10:36 AM, Resident #76 stated she was receiving her showers regularly until she transferred from skilled to long term care hallway. She stated she had not had a shower since she had been in her new room. Resident #76 stated the day she came in they asked her if she wanted a shower, but she had just gotten one the day before. Resident #76 stated she did not know if she was going to get a shower today, but she hoped she was. She said she transferred off the skilled unit on Friday (7/24/26) or Saturday (7/25/26). In an interview on 07/30/2026 at 9:38 AM, Resident #76 stated they had not given her a shower. She stated the nurse (unknown) told her she was going to receive a shower today. Resident #76 stated it did not make her feel great that she had not received a shower. She stated the nurse today told her that they could use a lift to get her up to be able to get a shower. Resident #76 stated the nurse asked her if she preferred morning or evening and she said she did not care. In an interview on 07/30/2026 at 9:44 AM, CNA B stated there was a shower tech that gave showers on the 2 pm to 10 pm shift. She stated she was not sure when Resident #76 had a shower. CNA B stated she did not know who the shower tech was. CNA B stated their shower tech left and then a new shower tech came for about a week and now a new shower tech was supposed to start. She stated about 2 weeks ago, the shower aide quit and they told them a new shower tech was supposed to start on Monday (7/27/26), but she did not know if that happened. CNA B stated no one on the 300 hall had gotten a shower that she knew of. In an interview on 7/30/26 at 9:58 am, LVN B stated they had a shower tech that worked on the 2 pm to 10pm shift. LVN B stated the shower tech quit on Friday, 7/24/26, but they were going to try to change the showers to morning. LVN B stated the CNA's would have to do their showers themselves. LVN B stated showers were very important to prevent urinary tract infections, yeast infections and showers were part of the residents well-being. LVN B stated Resident #76 had a bath on 7/24/26 and received showers on Monday, Wednesday, and Friday. LVN B stated Resident #76 should have had a shower on Monday (7/27/26) and Wednesday (7/29/26). LVN B stated giving residents showers helped them to see any skin conditions, toes, and more of anything the residents had. In an interview on 07/30/2026 at 1:29 PM, the DON stated she had 2 shower techs in the morning and 2 in the evening for the back halls. She stated one shower tech left with 2 weeks' notice and the 2nd shower tech took the position and she quit in one day. The DON stated they had a new shower tech that started on Monday. She stated she had never had a problem with showers. The DON stated the 200 hall's shower tech just put her notice in and someone on the 300 hall said they wanted the position. The DON stated if someone did not get a shower, then they give them a shower. The DON stated the only risk to not receiving a shower is that the residents would just stink. She stated Resident #76 was able to make her needs known and she had not heard anything about it. In a further interview on 7/30/26 at 1:39 pm with the DON and LVN B the DON asked about Resident #76 not getting a shower. LVN B stated Resident #76 received a shower on Friday (7/24/26). The DON told LVN B to get Resident #76 a bed bath or shower today 7/30/26. Record review of facility policy on Activities of Daily Living dated February 2017 and revised January 2023 revealed, Each resident's abilities to perform activities of daily living will not diminish unless the individual's clinical condition demonstrates that diminution was unavoidable. Activities of daily living include: personal hygiene.

Based on observation, interview and record review the facility failed to ensure the accurate acquiring, dispensing, receiving, and administering of medications for 1 of 2 medication carts (300 hall Medication Aide cart) and 1 of 4 (MA C) staff, reviewed for pharmacy services. MA C failed to properly dispose of a medication on 7/30/26 at 9:10am that was found on the 300 hall Medication Aide cart, by flushing a loose capsule down in the toilet. This failure could place residents at risk of misappropriation of medication, adverse reactions to medication, and injury.During an observation and interview on 07/30/26 at 9:10AM, the 300 hall Medication Aide cart had one loose small white capsule at the bottom of the second drawer beneath the blister packs. MA C picked up the capsule, disposed of the capsule by flushing it down in the toilet at a nearby resident's bathroom. MA C stated she put the capsule in the toilet because the toilet was close by and the surveyor was there. MA C stated she should have brought the medication to the nurse to ask what the facility procedure was for proper destruction of medication. MA C stated she did receive an in-service regarding medications and medication storage approximately 3 weeks ago that was conducted by the DON or the ADON. In an interview on 7/30/26 at 9:50AM, RN D stated if she found a loose pill/medication she would first identify to ensure it was not a narcotic, and would then give the narcotic to the DON for proper destruction but if it was a non-narcotic then she would put the pill in the sharps container. RN D stated loose pills could be picked up by a resident and they could ingest a medication that was not intended for them. RN D stated as far as she knew, this was the facility policy, and it would not be ok to flush any medication down in the toilet because it could get into the water system.In an interview on 7/30/26 at 10:10AM, MA E stated if she were to find a loose pill in her medication cart she would bring it to the DON for further instructions. MA E stated it would not be ok to flush a medication down the toilet because medications would be toxic to the water system. In an interview on 07/30/26 at 4:58PM, the DON stated the nurses, and medication aides were responsible for the medication carts. The DON stated loose pills should be disposed of in the sharps container and it would not be ok to flush down the toilet because that is not the facility policy. The DON stated that in recent past she conducted nursing staff in-services related to medications, skills check offs by facility and pharmacist to ensure the medication storage policy was being followed.Record review of the facility policy for Medication cart use and storage revised in January 2023 read in part: Compliance Guidelines: The nursing Team Members (Nurses & CMA's) use the medication cart to systemically distribute physician ordered medications to residents. Responsible Disciplines - Licensed nurses, C.M.A's.1. Security: the medication cart and its storage bins should be kept closed, secured and/or in the line of sight when not in use. If an emergency occurs during a medication pass, the nurse/medication aide should be closed, secured and/or in the line of sight before attending to the emergency.avoid placing medications on top of the cart unless pulling medications from the cart. The only exception would be if the cart and medications are within the direct line of sight of the authorized personnel. Note: Best practice is to avoid leaving medication on top of the cart.Record review of the facility policy for Medication Management, updated on 03/15/2019 read in part: Purpose: Medications are stored, dispensed and destroyed in a manner to ensure safety and conformance with state and federal laws. Responsible Disciplines - Licensed nurses, C.M.A's. Guidelines:.6. State law/guidelines should be followed for destruction of medications.

Based on observation, interview, and record review the facility failed to, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys for 2 of 4 medication carts (500 hall Nurse cart and 300 hall Medication Aide cart) and 1 of 4 staff (LVN B) reviewed for storage of medications. LVN B failed to lock the 500 hall Nurse medication cart on 7/29/26 at 7:06am, before walking away to assist a resident who was at the end of the 500 hall. LVN B failed to secure a medication on 7/29/26 at 7:06am, before walking away from the medication cart to assist a resident at the end of hall 500. An insulin pen was left on top of the 500 hall Nurse medication cart. These failures could place residents at risk of misappropriation of medication, adverse reactions to medication, and injury. Findings included: During an observation and interview on 07/29/26 at 7:06 AM, LVN B was in hall 500 preparing to enter a resident room to administer insulin. LVN B turned her back and walked away from the medication cart to assist a resident who was at the end of the hall. The medication cart was unlocked, and the insulin pen was on top of the medication cart. There were no other residents around the medication cart at the time. LVN B was able to summon another nursing staff member to assist the resident back inside his room and LVN B walked back to the medication cart. LVN B stated before leaving the cart she should have secured the insulin pen inside the medication cart and locked the cart before walking away. LVN B stated anyone could have removed medication if the cart was unlocked. LVN B stated she forgot because she was nervous. In an interview on 07/30/26 at 4:58PM, the DON stated the nurses, and medication aides were responsible for the medication carts. The DON stated the medications carts should be secured if not within eye view of the nurse or medication aide and any medication should be secured in the cart before walking away. The DON stated if no one was around the cart then it would not be an issue if the medication cart were unlocked. The DON stated that in recent past she conducted nursing staff in-services related to medications, skills check offs by facility and pharmacist to ensure the medication storage policy was being followed. Record review of the facility policy for Medication cart use and storage revised in January 2023 read in part: Compliance Guidelines: The nursing Team Members (Nurses & CMA's) use the medication cart to systemically distribute physician ordered medications to residents. Responsible Disciplines – Licensed nurses, C.M.A's.1. Security: the medication cart and its storage bins should be kept closed, secured and/or in the line of sight when not in use. If an emergency occurs during a medication pass, the nurse/medication aide should be closed, secured and/or in the line of sight before attending to the emergency.avoid placing medications on top of the cart unless pulling medications from the cart. The only exception would be if the cart and medications are within the direct line of sight of the authorized personnel. Note: Best practice is to avoid leaving medication on top of the cart. Record review of the facility policy for Medication Management, updated on 03/15/2019 read in part: Purpose: Medications are stored, dispensed and destroyed in a manner to ensure safety and conformance with state and federal laws. Responsible Disciplines – Licensed nurses, C.M.A's. Guidelines:.6. State law/guidelines should be followed for destruction of medications.

Number of residents sampled: Number of residents cited: Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for 3 of 10 hot plate covers reviewed for food service safety.- The facility failed to remove 3 chipped/broken hot plate covers from available clean service ware per the facility's policy, on 7/28/26.This failure could place residents at risk of skin injuries and/or infections.The findings included:Observation and interview on 07/28/26 at 8:55 a.m., the Dietary Manager revealed 3 chipped hot plate covers on a dish rack in the back of the kitchen by the dish machine where all the clean dishes were that were being used. She said she performs walk through audits once a month and asked her staff to throw away any chipped/broken dishware. The Dietary Manager removed the hot plate covers from circulation. She said a resident could potentially have tearing to their skin if contact with a chipped/broken cover was made.During a follow-up interview on 07/30/26 at 12:09 p.m., the Dietary Manager said systematically she had been pulling broken hot plate covers. She said an order for more was placed yesterday, (7/29/26), and expected delivery on Monday, 8/3/26.Record review of the facility's policy, The Dining Environment, (C)2018, revealed .9. Glassware and china will be clean and free of chips.

Number of residents sampled: Number of residents cited: Based on observation, interview, and record review, the facility failed to maintain an effective pest control program for 2 of 13 rooms (Resident #110 and Resident #1) reviewed for environmental concerns. -On 7/30/26 at 10:10 am, the facility failed to provide an effective pest control program as evidenced by live spiders being observed on the wall in Resident #110's room (room [ROOM NUMBER]). -On 07/30/26 at 11:30 AM, the facility failed to provide an effective pest control program as evidenced by a live spider in Resident #1's hair while in room [ROOM NUMBER]. These failures could place residents at risk of living in an unsafe, unsanitary, and uncomfortable environment. Findings include: Record review of Resident #110's face sheet dated 07/30/2026 revealed she was an [AGE] year-old female who was originally admitted to the facility on [DATE] and admitted on [DATE]. Her admitting diagnoses included metabolic encephalopathy (brain dysfunction), type 2 diabetes mellitus (high blood sugar), hypertension (high blood pressure), atrial fibrillation (irregular heart beat), hyperlipidemia (high cholesterol), chronic kidney disease (kidneys cannot filter blood properly), atherosclerotic heart disease (stiffening and thickening of blood vessels in the heart), muscle weakness, and abnormalities of gait and mobility (difficulty walking). Record review of Resident 110's care plan updated 07/10/2026 revealed a diagnosis of metabolic encephalopathy with a goal to participate in care with ADLs and required 1 staff for dressing and grooming and personal hygiene. Record review of Resident #1's face sheet dated 07/29/26 revealed a [AGE] year-old admitted on [DATE] and initially admitted on [DATE] with diagnoses to include anoxic brain damage (brain deprived of oxygen), pneumonitis (inflammation of the lungs), aphasia (language disorder caused by damage in a specific area of the brain), acute and chronic respiratory failure; heart disease, Arteriosclerosis of coronary artery bypass graft (progressive narrowing of graft vessels), elevated blood pressure and gastrostomy status (a surgically created opening in the abdomen directly into the stomach with a feeding tube). Record review of Resident #1's quarterly MDS (resident assessment and care screening), dated 06/12/26 revealed, he had no speech, the BIMS summary score was blank, his cognitive skills for daily decision making were severely impaired, he had impairment to one side of upper extremity and one side of lower extremity. Resident #1 was dependent on staff assistance for oral hygiene, toilet hygiene, shower/baths, dressing, and personal hygiene. Resident #1 does none of the effort to complete activities such as rolling in bed and transfers. Resident used a manual wheelchair as a mobility device. Resident #1 was always incontinent of bowel and bladder. Resident #1 required a feeding tube as a nutritional approach. Resident #1 required tracheostomy care. Record review of Resident #1's care plan last reviewed on 05/26/26 revealed: Focus - Resident #1 had communication problems r/t Expressive Aphasia, Anoxic Brain damage. Interventions included - observe for physical and nonverbal indicators of discomfort or distress and follow up .as needed. Focus - Resident #1 had a potential for alterations in skin integrity r/t friction, immobility, and contractures. Interventions included - observe skin while providing care, report to nurse any skin concerns noted. In an observation and interview on 7/30/26 at 10:10 am with Resident #110 observation revealed a spider web by Resident #110's privacy curtain. Resident #110 stated spider web made her feel afraid. She stated she went out of control when she saw a spider. Further observation of Resident #110's room revealed a spider web on the top of the wall in the corner by Resident #110's bed, and observation revealed a spider at the top of the wall at front door in the corner and there was another spider web. Resident #110 stated that to her all spiders were deadly. In an interview on 7/30/26 at 10: 24 am, the House Keeping and Laundry Supervisor stated the facility had a quality controlled inspection and it broke it down for the bathroom and living area of the resident. She stated cleaning of the blinds, overhead light, bedside tables sanitized, furniture sanitized, base boards and edges being cleaned, toilet, sink, showers, and floor were being swept and sanitized. She stated the facility used a 5-step process. She stated they did these inspections daily and they randomly chose a room from each of the housekeepers rooms and they check randomly down the checklist. She stated she had not selected any resident rooms yet today, 7/30/26. In an observation and interview on 07/30/2026 at 11:19 AM with CNA D she stated the object that was located in Resident #110's room looked like a spider with spider webs. In an observation and interview on 07/30/26 at 11:30 AM, Resident #1 was lying on his back in bed, alert and non-verbal. A small white spider was crawling fast from the pillow and into Resident #1's hair on the right side of his head. Surveyor notified CNA C who was standing nearby. CNA C was able to find the spider and squish it dead with her fingers. CNA C stated she had never seen any spiders or other insects before in the facility and that she would notify the DON about the spider found on Resident #1. CNA C stated she had seen pest control around spray rooms at times but did not recall the last time. CNA C stated Resident #1 was bed bound and would not be able to remove the small spider away from himself if he knew it was there. In an interview on 7/30/26 at 4:25 pm, the Maintenance Director stated the facility completed monthly pest control and if they had any issues in between that time, they would call pest control. He stated that pest control did spray for spiders, both outside the facility and the interior. He stated that spider webs were a housekeeping thing. The Maintenance Director stated that they had pest control to spray in every room monthly. The Maintenance Director was informed that there was a live spider in room [ROOM NUMBER] and room [ROOM NUMBER] and spider webs in rooms 313, 316 and 314. In an interview on 07/30/2026 at 5:18 PM, the DON stated housekeeping was responsible to make sure there were no spider webs in the residents' rooms. She stated housekeeping was supposed to clean the room but if the staff see anything they let housekeeping know. The DON stated they have the If you see something say something watch. She stated they want to make sure they do not have any pests. The DON stated the danger of having an unharmful spider is none, but if it's a harmful spider then there is a possibility of getting bitten. She stated that if she or a resident saw a spider they might have been alarmed. The DON stated she was not aware of the spider on Resident #1 and that Resident #1 was able to move his arms up and down if he needed to. Record review of facility policy on Physical Environment dated February 2017 and revised January 2023 revealed: Pest control-The community maintains an effective pest control program so that the community is free of pests and rodents. An effective pest control program is defined as measures to eradicate and contain common household pests (e.g., roaches, ants, mosquitoes, flies, mice, and rats).

Based on interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections to meet the needs of 2 of 5 residents (Resident #1 and Resident #2) reviewed for infection control.The facility failed to enter Resident #1's contact isolation orders in her electronical medical record and failed to initiate contact precautions for Resident #1 who was positive for c.difficile (a bacterium that causes an infection of the colon) for 2 days.The facility failed to separate Resident #2 from Resident #1, who had a confirmed c. difficle infection, in a timely manner.This failure could place residents at risk of spread of infection.The findings included:Record review of Resident #1's admission record dated 7/18/26 revealed an [AGE] year-old female who readmitted on [DATE]. Her diagnoses included acute respiratory failure (when your lungs cannot deliver enough oxygen or remove enough carbon dioxide from your blood), chronic obstructive pulmonary disease (an ongoing lung condition caused by damage to the lungs), legal blindness, anxiety, and type 2 diabetes.Record review of Resident #1's discharge, return anticipated MDS assessment dated [DATE] revealed her cognitive skills for daily decision making were modified independence. She required partial/moderate assistance from staff with toileting hygiene. Record review of Resident #1's care plan report completed 6/5/26 revealed she was at risk for infection or recurrent/chronic infection related to compromised medical condition. Interventions were to report changes in condition to the MD as clinically indicated.Record review of Resident #1's nursing note dated 6/10/26 at 12:32 p.m. written by LVN W revealed in part, .Resident reports having nausea, vomiting, diarrhea last couple of days on/off. Notified. NP ok for stat cbc/cmp/collect stool for c-diff/ Zofran 4 mg po TID prn nausea and vomiting x 7 days. (A cbc evaluates blood cells, while a cmp assess organ function and metabolic balance. A stool tests for C. diff detects the presence of toxin-producing bacteria in individuals with diarrhea). Record review of Resident #1's undated Lab Results Report for her C-Difficile stool sample revealed the lab reported the results to the facility on 6/11/26 at 9:47 p.m. The facility reviewed the results on 6/12/26 at 2:50 p.m. The result of the stool test was detected which indicated the specimen contained toxigenic (producing a toxin) C difficle strain with pathogen locus (refers to a specific location in the genome of a pathogenic microorganism that contains genes or genetic elements directly involved in causing disease).Record review of Resident #1's nursing note dated 6/12/26 at 2:50 p.m. written by LVN D revealed in part, .Results for C-Diff showing detected. Notified NP of results. Awaiting orders at this time. Monitoring.Record review of Resident #1's nursing note dated 6/12/26 at 3:11 p.m. written by LVN D revealed in part, .New order for Vancomycin 125 mg. use contact precautions.Record review of Resident #1's Order Summary Report revealed an order for isolation: contact isolation precautions: ensure infection site is contained prior to leaving room. If not able to contain infection source, then resident/patient should remain in room for all care/services, every shift, order date 6/14/26. There were no isolation orders entered prior to 6/14/26.Record review of Resident #1's nursing note dated 6/13/26 at 9:32 a.m. by LVN L revealed in part, .resident currently taking Vancomycin x 10 days for C-diff, resident assisted to bathroom, no loose stool noted at this time, fluids encouraged.Record review of Resident #1's nursing note dated 6/14/26 at 1:35 p.m. by LVN L revealed in part, .remains on Vanco q 6 x 10 days for C-diff, resident in room with contact isolation precautions in place.Family aware of C-diff precautions.Record review of Resident #1's census revealed she was in a semiprivate room [ROOM NUMBER]-A from 12/11/25 - current.Record review of Resident #1's nursing note dated 6/15/26 at 7:10 p.m. by LVN E revealed in part, .911 called to transport resident to hospital d/t lethargic.Resident #2Record review of Resident #2's admission record dated 7/18/26 revealed [AGE] year-old female who readmitted on [DATE]. Her diagnoses included metabolic encephalopathy (a change in how your brain works due to an underlying condition. It can cause confusion, memory loss and loss of consciousness), dementia, and muscle weakness.Record review of Resident #2's significant change in status MDS assessment dated [DATE] revealed her cognitive skills for daily decision making were severely impaired. She was dependent on staff for all ADL care except eating which she needed supervision or touching assistance.Record review of Resident #2's care plan reviewed on 6/17/26 revealed she was at risk for significant infections and/or recurrent infections related to compromised medical condition, revised on 6/21/25.Record review of Resident #2's nursing note dated 6/14/26 at 1:15 p.m. revealed in part, .Spoke with. RP for resident and notified that we would be moving. (Resident #2) to 309-B, due to isolation precaution, stated, it was ok,:.Record review of Resident #2's census revealed she was roommates with Resident #1 in room [ROOM NUMBER] until 6/14/26 when she was moved to 309-B.In an interview on 7/18/26 at 12:50 p.m. CNA O said Resident #1's stool was very loose approximately 3-4 weeks ago, and she was having diarrhea in the restroom which was reported to the nurse. She said a couple of days later the resident was unable to get out of bed and her stool was still very loose. Her stool smelled like c. diff but the facility did not confirm that she had something (an infection). She said the facility moved the Resident #2 out of the room before they put the precautions out. She said contact precautions for Resident #1 including the PPE cart were set up the day before the resident was sent out to the hospital. She said she did not gown up when caring for the resident prior to them putting the precautions in place and was changing the resident without gowns. She said she had not received an in-service on infection control since she had been at the facility. In an interview on 7/18/26 at 1:11 p.m. Resident #1's family member said the resident had diarrhea and vomiting, she was in bed and could barely make it to the restroom. He said the first weekend of June (6/6/26 - 6/7/26) he reported it and the nurse gave her some medication, but she was not getting better. He said the resident was confused and did not remember right now.In an interview on 7/18/26 at 1:20 p.m. Resident #1 said before going to the hospital she had diarrhea, vomiting, and had a stomach virus/ colon infection. In an interview on 7/18/26 at 1:31 p.m. LVN D who worked the day shift on 6/12/26 said she barely remembered that day and was working prn at the time. She said she did not recall setting up isolation for Resident #1 but she wanted to say she probably initiated it. She said the facility might have been isolating both Resident #1 and Resident #2 because they shared a room. She said sometimes there was no place to move the roommate to. In an interview on 7/18/26 at 1:48 p.m. the DON said Resident #1's c. diff results returned to facility on 6/11/26 at 9:47 p.m. In an interview on 7/18/26 at 2:34 p.m. the DON said the facility normally placed a resident on isolation when positive for c. difficle. She said Resident #1 was put on isolation which was put into place on 6/14/26 if going by the order in the system. She said a positive c.difficle result did not require a single room because the infection was in the stool. She said she would have to investigate if her staff were using PPE with Resident #1 (between the day they found out she was positive for c. diff [6/12/26] and when the order was put in [6/14/26]) because she did not know.In an interview on 7/18/26 at 2:44 p.m. the Administrator said as soon as the facility was made aware of the positive c.diff result she expected staff to follow protocol, alert the staff, and re-educate staff so they know what to do. She said entering the contact precaution order was part of the facility protocol and the purpose was for notification reasons and to ensure everyone followed the order.In an interview on 7/18/26 at 3:08 p.m. LVN L said Resident #1 was being treated for c.diff and was on contact precautions. She said when the MD saw the resident on Saturday (6/13/26) she could not remember if the resident was on contact precautions and did not remember the exact date she was placed on contact precautions. She said she did not recall when her roommate (Resident #2) was moved. She said she did not know the facility tested her for c. diff but when she was informed she was positive she always gowned up and followed the signage in place. In an interview on 7/18/26 at 4:46 p.m. the DON said Resident #1 was the only resident to have c.difficle before and after her hospitalization (on 6/15/26).In an interview on 7/18/26 at 4:36 p.m. the DON said the facility did not have a policy on MD orders.In an interview on 7/18/26 at 5:44 p.m. the DON said all nurses were responsible for entering orders timely. She said there was no risk to Resident #2 due to the residents not sharing any areas, past 3 feet from each other and Resident #2 could not walk. She said the contact precaution orders were put in late but said the isolation bins were there and staff would have had isolation gear on. She said floor staff were responsible for setting up isolation. Record review of the facility's Infection Prevention and Control policy revised April 2024 revealed in part, .The elements of the infection prevention and control program consist of coordination/oversight, guidance/procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety.9. Prevention of infection a. important facets of infection prevention include: . 9. Implementing appropriate isolation precautions when necessary.In addition to Standard Precautions, Contact Precautions may be implemented for a resident known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or patient-care items in the resident's environment. A. examples of infections requiring Contact Precautions include, but are not limited to: . clostridium difficile.b. resident placement: place the resident in a private room. When a private room is not available, a resident with the same infection with the same microorganism, but with no other infection, may be co-horted. d. Gown: .wear a gown (clean, non-sterile) when entering the room if you anticipate that your clothing will have substantial contact with the resident or contaminated surfaces.

Based on interview and record review, the facility failed to promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician's orders for 1 of 5 residents (Resident #1) reviewed for physician notification of laboratory services.The facility failed to review Resident #1's stool test results for c. difficile (a bacterium that causes an infection of the colon) and notify the MD/NP in a timely manner. The results were reviewed and NP was notified approximately 17 hours after the results were sent to the facility.This failure could place residents at risk of delayed treatment and spread of infection.The findings included:Record review of Resident #1's admission record dated 7/18/26 revealed an [AGE] year-old female who readmitted on [DATE]. Her diagnoses included acute respiratory failure (when your lungs cannot deliver enough oxygen or remove enough carbon dioxide from your blood), chronic obstructive pulmonary disease (an ongoing lung condition caused by damage to the lungs), legal blindness, anxiety, and type 2 diabetes.Record review of Resident #1's discharge, return anticipated MDS assessment dated [DATE] revealed her cognitive skills for daily decision making were modified independence. She required partial/moderate assistance from staff with toileting hygiene. Record review of Resident #1's care plan report completed 6/5/26 revealed she was at risk for infection or recurrent/chronic infection related to compromised medical condition. Interventions were to report changes in condition to the MD as clinically indicated.Record review of Resident #1's Order Summary Report revealed an order for stat (immediately or without delay) cbc/cmp/collect stool for c-diff one time only for lab monitoring for 4 days, order date 6/10/26. (A cbc evaluates blood cells, while a cmp assess organ function and metabolic balance. A stool tests for C. diff detects the presence of toxin-producing bacteria in individuals with diarrhea). Record review of Resident #1's nursing note dated 6/10/26 at 12:32 p.m. written by LVN W revealed in part, .Resident reports having nausea, vomiting, diarrhea last couple of days on/off. Notified. NP ok for stat cbc/cmp/collect stool for c-diff/ Zofran 4 mg po TID prn nausea and vomiting x 7 days.Record review of Resident #1's nursing note dated 6/10/26 at 3:00 p.m. written by LVN W revealed in part, .Collect small amount of brownish-green soft bowel movement noted placed specimen in cup labeled and placed in cooler.Record review of Resident #1's NP visit note dated 6/11/26 at 11:30 a.m. written by the MD revealed in part, .(Resident #1).is seen today. she is awake and alert with no acute distress. She reports feeling tired today and has been having diarrhea since yesterday. Care Coordination: Stool collected and sent to lab to rule out C. difficile; results pending. Started on Rocephin 1 g IM daily x 3 days for leukocytosis (high white blood cell count). with diarrhea. Follow-up.monitor for C. difficile stool test results.Record review of Resident #1's nursing note dated 6/11/26 at 12:14 p.m. written by LVN W revealed in part, .Notified [NP] regarding resident still having loose stools. Lab reviewed.Stool culture still pending at this time.Record review of Resident #1's undated Lab Results Report revealed her C-Difficile stool sample was collected by the facility on 6/10/26 at 5:12 p.m. The lab received the sample on 6/11/26 at 7:35 p.m. The lab reported the results to the facility on 6/11/26 at 9:47 p.m. The facility reviewed the results on 6/12/26 at 2:50 p.m. The result of the stool test was detected which indicated the specimen contained toxigenic (producing a toxin) C difficle strain with pathogen locus (refers to a specific location in the genome of a pathogenic microorganism that contains genes or genetic elements directly involved in causing disease).Record review of Resident #1's nursing note dated 6/12/26 at 2:50 p.m. written by LVN D revealed in part, .Results for C-Diff showing detected. Notified NP of results. Awaiting orders at this time. Monitoring.Record review of Resident #1's nursing note dated 6/12/26 at 3:11 p.m. written by LVN D revealed in part, .New order for Vancomycin 125 mg. use contact precautions.In an interview on 7/18/26 at 1:11 p.m. Resident #1's family member said the resident had diarrhea and vomiting, she was in bed and could barely make it to the restroom. He said the first weekend of June (6/6/26 - 6/7/26) he reported it and the nurse gave her some medication, but she was not getting better. He said the resident was confused and did not remember right now.In an interview on 7/18/26 at 1:20 p.m. Resident #1 said before going to the hospital she had diarrhea, vomiting, and had a stomach virus/ colon infection. In an interview on 7/18/26 at 1:31 p.m. LVN D who worked the day shift on 6/12/26 said she barely remembered that day and was working prn at the time. She said she always had a list of labs that were pending results, and as the day progressed, she would check the electronic medical record for laboratory or diagnostic results and sometimes did not get results until 4 p.m. She said if laboratory results were an emergency or had a critical value, the lab would call the facility. She said the facility would like to have the results as soon as available and someone may not have checked Resident #1's results prior to her shift. In an interview on 7/18/26 at 1:48 p.m. the DON said nursing staff should check the electronical medical record for laboratory results every shift and results were also reviewed in morning meeting by the IDT. She said lab orders should be reviewed and the NP/MD notified with results. She said Resident #1's c. diff results returned to facility on 6/11/26 at 9:47 p.m. and the Vancomycin was started on 6/12/26. In an interview on 7/18/26 at 2:31 p.m. the Administrator said during morning meeting on 6/10/26 the IDT discussed Resident #1's nausea/vomiting concerns. She said there was no documentation regarding Resident #1 at the 6/11/26 meeting and on 6/12/26 the IDT discussed her cbc labs but did not have documentation about a positive c-diff test.In an interview on 7/18/26 at 2:34 p.m. the DON said she always told her staff to review lab/diagnostic results every shift and to look when first coming on shift, try to look in the middle of the shift, and look when they were closing out the shift. She said it was important to monitor for lab results so nursing staff could report any abnormal labs to the MD/NP. In an interview on 7/18/26 at 5:32 p.m. the DON said all nurses were responsible to ensure lab results were read in a timely manner. She said there was no risk to Resident #1 because staff were aware something was going and she was already on an antibiotic.In an interview on 7/18/26 at 5:33 p.m. LVN E said she tried to check the laboratory results every night and day shift would report if there were pending results. She said if the results were not available upon starting the shift, she would check again after her first round. She said she might have been busy that night (6/11/26) and sometimes the other residents needed her and pulled her away and could not see the results in a timely manner. She said she did not recall seeing Resident #1's results and did not remember being notified that a stool test was collected on Resident #1.Record review of the facility's Critical Laboratory Value Reporting staff education dated 4/22/26 read in part, .Purpose: to ensure timely reporting, communication, documentation, and follow-up of critical laboratory values to promote resident safety and meet regulatory standards. Definition: a critical laboratory value is a test result that falls outside of normal limits and may indicate a life-threatening or emergent condition requiring immediate clinical intervention. Expectation: all critical laboratory values must be received by a licensed nurse, verified with read-back, reported immediately to the provider, documented completely, and acted upon without delay. Critical labs may not be held for routine review, shift change, or rounds. Roles and responsibilities: Licensed nurse: receives and verifies results, assesses resident, notifies provider, implements orders, and documents actions.

Based on interview and record review, the facility failed to transmit encoded, accurate, and complete MDS data to the Center for Medicaid/Medicare System (CMS) System for 3 of 6 closed records (CR #1, #2 and #3) reviewed for Minimum Data Set (MDS) transmission. CR #1, CR #2 and CR #3's discharge MDS assessment was not completed and transmitted within 14 days of CR's discharges. This failure could place residents at risk of not having assessments completed and submitted in a timely manner as required. The findings were: Record review of CR #1's Facesheet dated 03/20/2025 revealed CR #1 was a 79-years old male who originally admitted to the nursing facility (NF) on 11/15/2022 and readmitted on [DATE] and discharged on 02/03/2025. CR #1's diagnosis included but were not limited to non-st elevation (nstemi) (a type of heart attack that doesn't show the characteristic) myocardial infarction (a type of heart attack characterized by a partial blockage of a coronary artery, leading to reduced blood flow and heart muscle damage), presence of aortocoronary bypass graft (surgical procedure to improve blood flow to the heart), atherosclerotic heart disease of native coronary artery without angina pectoris (a condition where the coronary arteries, which supply blood to the heart, become narrowed or blocked by the buildup of plaque), and heart failure (heart cannot pump enough blood meet the body's needs). Record review on 05/14/2025 at 10:14 a.m. revealed that CR #1's MDS discharge annual review date (ARD) had been due on 02/03/2025 and had been 86 days overdue. Record review of CR #1's January 2025 billing invoice dated 01/06/2025 to 01/31/2025 reflected the CR had been invoiced for a 26-day stay at the nursing facility (NF). Record review of CR #1's February 2025 billing invoice dated 02/01/2025 to 02/03/2025 reflected the CR had been invoiced for a 2-day stay at the NF. Record review of CR #2's Facesheet dated 03/20/2025 revealed CR #2 was an 86-years old female who originally admitted to the NF on 12/24/2024 and discharged on 01/09/2025. CR #2's diagnosis included but were not limited to hypertension (common condition where the force of blood against the artery walls is consistently too high) hyperlipidemia (a condition where there are elevated levels of fats (lipids) in the blood), osteoarthritis (breakdown of cartilage and the underlying bone causing pain, stiffness, and basal cell carcinoma of skin (cancer caused by sun exposure). Record review on 05/14/2025 at 10:38 a.m. revealed that CR #2's MDS discharge ARD had been due on 01/09/2025 and had been 111-days overdue. Record review of CR #2's December 2024 billing invoice dated 12/24/2024 to 12/31/2024 reflected the CR had been invoiced for an 8-day stay at the NF. Record review of CR #2's January 2025 billing invoice dated 01/01/2025 to 01/09/2025 reflected the CR had been invoiced for a 8-day stay at the NF. Record review of CR #3's Facesheet dated 03/20/2025 revealed CR #3 was a 79-years old female who originally admitted to the NF on 12/31/2024 and discharged on 01/13/2025. CR #3's diagnosis included but were not limited to specified fracture of left pubis (a break in the pubic bone on the left side of the pelvis). Record review on 05/14/2025 at 10:37 a.m. revealed that CR #3's MDS discharge ARD had been due on 01/13/2025 and had been 107 days overdue. Record review of CR #3's December 2024 billing invoice dated 12/31/2024 to 12/31/2024 reflected the CR had been invoiced for an 1-day stay at the NF. Record review of CR #3's January 2025 billing invoice dated 01/01/2025 to 01/13/2025 reflected the CR had been invoiced for a 12-day stay at the NF. During an interview on 05/15/2025 at 01:41 p.m., MDS Coordinator stated CR#1, CR#2, and CR #3's MDS assessments had not been transmitted and it had been her responsibility to upload them timely. She stated she had safeguard mechanisms in place to assist with uploading timely such as a MDS schedule, and discussions during morning manager meetings, but due to the NF's high resident turnover the assessments had been missed. She stated that the negative outcomes of not uploading the assessments timely could result in assessments being left open, not correctly reflecting a resident's discharge outcome to the community, and cause discrepancy with the business offices billing functions. During an interview on 05/15/2025 at 02:14 p.m., the Business Office Manager (BOM) stated that she had not been aware that CR#1, CR#2, and CR #3's MDS assessments were not completed. She stated it had been MDS Coordinator's responsibility to complete the assessments. She stated that the completion of the MDS assessments determined the days needed to bill a resident's insurance company. She stated failure to complete the assessments timely could result in incorrect billing. She stated she was unaware if there were any billing issues as a result of the late assessments. During an interview on 05/15/2025 at 02:39 p.m., LVN D stated that she had been responsible for creating a discharge log to alert when and which residents were scheduled for discharge. She stated when a resident was scheduled for discharge, she sent an email to management to include the MDS Coordinator. She stated once MDS Coordinator received the email she was to have begun the MDS discharge process/assessments. She stated that MDS Coordinated was alerted by way of email that of CR#1, CR#2, and CR #3's discharges from the NF and MDS Coordinated confirmed receipt of the emails relating to the CR's discharges. During an interview on 05/15/2025 at 02:54 p.m., the Director of Nursing (DON) stated it had been her expectation that MDS assessments were completed timely and followed through based on the company's protocols. She stated that the negative outcomes of not completing the MDS assessments timely could result in an incorrect calculation of days within the NF for billing purposes. During an interview on 05/15/2025 at 03:10 p.m. the Administrator stated that she was not aware of CR#1, CR#2, and CR #3's incomplete MDS Assessments. She stated that discharges were discussed in every morning meeting, and they were presented a roster of discharged residents. She stated that she was not aware how a resident discharged could have been missed. She stated it had been her expectations that MDS assessments were completed in a timely manner. She stated that the negative outcomes of not completing the MDS assessments timely could result in an incorrect calculation of days within the NF for billing purposes. Record review of NF policy dated Date Implemented: February 2017 Date Revised: September 2022 and titled Admission, Transfer, and Discharge Compliance Guidelines: A physician extender may complete documentation of the transfer/discharge unless prohibited by state law or community policy. Preparation and orientation for discharge or transfer. Preparation and orientation are essential to ensure safe and orderly transfer or discharge from the community. Sufficient preparation means that the community informs the resident where he or she is going and takes steps under its control to ensure safe transportation. In addition, the community involves the resident and the resident's family in selecting the new residence. Medicaid Residents: In the case of a person eligible for Medicaid, a nursing community must not charge, solicit, accept, or receive, in addition to any amount otherwise required to be paid under the State Plan, any gift, money, donation, or other consideration as a precondition of admission, expedited admission, or continued stay in the community. However, a nursing community may: 1. charge a resident who is eligible for Medicaid for items and services the resident has requested and received, and that are not specified in the State Plan as included in the term nursing community services: so long as the community gives proper notice of the availability and cost of these services to residents and does not condition the resident's admission or continued stay on the request for and receipt of these additional services; and 2. solicit, accept, or receive a charitable, religious, or philanthropic contribution from an organization or from a person unrelated to a Medicaid-eligible resident or potential resident, but only to the extent that the contribution is not a condition of admission, expedited admission, or continued stay in the community for a Medicaid-eligible resident. Discharge Planning: Discharge planning begins prior to the resident's admission and continues throughout the resident's stay. The purpose of discharge planning is to identify the resident's specific needs after discharge, such as personal care, sterile dressings, and physical therapy, and describes resident/caregiver education needs and the ability to meet care needs after discharge. Discharge planning will also help the community determine whether the resident can go to al ess restrictive environment, such as assisted living, home, residential community, group home, or another community-based situation. The community will utilize a multidisciplinary approach involving the communities' team members, the resident and responsible party, family members, friends, post discharge caregivers, and support persons who will help the residents adjust to his or her new living environment. Record review of NF policy dated Date Implemented: February 2017 Date Revised: January 2023 and titled Care Plans reflected: The community develops a comprehensive care plan for each resident that includes measurable objectives to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment. The care plan should be reflective of the identified problem or risk, a measurable outcome objective and appropriate intervention/interventions in relation to the identified problem or risk, outcome objective, and the resident's ability, needs, medical condition, preventative measures. The care plan may also include the expressed preferences. The care plan in conjunction with the plan of care throughout the medical record is developed and or recommended to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Interdisciplinary means that professional disciplines work together to provide the greatest benefit to the resident. The Interdisciplinary Determination Team (IDT) should include within the care plan the right to refuse any recommended care, treatment or services identified but, that is not provided due to the resident exercising his or her right to refuse care, service, or treatment, as well as the resident's legal representative acting on behalf of the resident. ? The goal or outcome objection should be measurable; however, not every goal or outcome objective must have an interdisciplinary approach. ? The care plan should be initiated upon admission, continued to be developed during the initial 48-72 hrs., throughout the completion of the admission comprehensive assessment. The care plan should be updated and reviewed at least quarterly thereafter, then annually and with significant changes in conditions as defined in the Resident Assessment Instrument (RAI) manual. Additional updates to the care plan may be done as indicated. ? The care plan should be developed no later than seven days following the completion of the comprehensive assessment. ? The care plan should be prepared, reviewed and updated in accordance with the RAI guidance on a routine cadence (admission, quarterly, annually and with significant change). Additionally, the care plan should be modified as appropriate and on an as needed basis as per the RAI instructions. The care plan should be reflective of the resident's/representative's input, goals, and desired outcomes and should include the interdisciplinary team, to include but not limited to the attending physician, a registered nurse with responsibility for the resident, and other appropriate team members in disciplines as determined by the resident's needs. ? The care plan development should involve participation of the resident and his or her family or legal representative.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services, in that: The facility failed to ensure the ice machine was free from items (wet towel) within the stored ice. These failures could place residents at risk for food borne illness. The findings included: In an observation on 05/13/2025 at 8:31 a.m., during the Nursing Facility (NF)'s initial kitchen tour of 1 of 1 ice machines laid a moist white towel a crossed the opening of the machine where the machine's door rested closed. Upon opening of the ice machine door, the towel was observed resting just at atop of the ice near the opening of the machine. Upon the DM's observation of the towel, the DM immediately removed the towel and on the side that the towel that rested inside the machine, ice was observed stuck to the bottom of the towel. When the towel was quickly removed by the DM, some ice pieces flew off the bottom of the towel a crossed the room from the force of the DM's removal from the machine. In an interview on 05/13/2025 at 08:32 a.m., the DM stated that the white towel had been laid on the opening of the ice machine to capture moisture that accumulated in that area. She stated she was unaware who placed the towel there, but it should not have been there as it was an infection control issue. In an interview on 05/14/2025 at 03:26 p.m., the DM stated that the maintenance director empty, cleaned, and sanitized the ice machine after the towel was observed within. She stated a sign was placed on the machine while it was with going cleaning and the staff were in-service and educated to not leave towels or anything resting inside the ice machine. She stated leaving a wet towel within the ice machine left the ice susceptible to cross contamination and with the facility's high-risk residents, left the residents at risk of contact with bacteria because that ice would then be dirty. She stated she was not sure who was responsible for the placement of the towel, but the kitchen staff were educated to just wipe down the ice machine as condensation as it accumulated and remove the towel from the area. In an interview on 05/14/2025 at 3:54 p.m., the DON stated that the kitchen staff were in serviced on the hazards of infection control issues relating to the wet towel resting within the ice machine. She stated that residents were at risk of infections from whatever could have been on the towel that rested against the ice in the ice machine and would not have been favorable ice to consume. In an interview on 05/15/2025 at 3:10 p.m., the Administrator stated that the ice machine had been cleaned and placed out of service by the maintenance department on 04/24/2025 and on 05/13/2025 after the towel was discovered resting within. She stated that on 04/24/2025 she nor the maintenance department or the dietitian observed a towel on the ice machine and had they, they would have immediately removed the towel, and in-service staff on the infection control and infection issues having a towel resting on ice could place resident at risk of. Record review of policy undated and Policy: Ice Machines. Policy. The facility will maintain the ice machine:, scoop and storage container in a sanitary manner to minimize the risk of food hazards. The ice machine will be cleaned once per month or more often as needed. The scoop and storage container will be cleaned once each day. Procedure: l. Unplug ice machine and remove ice. 2. Wash interior with detergent solution. 3. Rinse and drain with hot water. 4. Sanitize and air dry. 5. Clean the exterior with detergent solution and rinse. 6. Clean underneath and around the machine. 7. Wash and sanitize the ice scoop at least once each day in the dishwasher and air dry. 8. Store the ice scoop in a clean non-porous container that allows water to drain off. 9. Use the scoop to serve ice. Place only in clean containers or glasses. 10. Use fresh ice only. Do not reuse ice. Record review of in-service training dated 05/13/2025 and titled Training/Retraining. Topic: Proper handling of ice machine. Ice machine will maintain free of leaks and free of risk of contamination (example: no towels). Signed by DM.

Based on observation, interview, and record review, the facility failed to provide a clean, comfortable, and homelike environment including a clean bed in good condition for 1 of 9 Resident's (Resident #4) whose bed was observed for sanitation. The facility failed to change Resident #4's bed linen which had several spills. This deficient practice could affect any resident and result in dissatisfaction and poor self-esteem. The findings were: Review of Resident #4's face sheet, dated 05/14/25, revealed she was re-admitted to the facility on [DATE] with diagnoses including: Nonalcoholic Steatohepatitis (NASH) (the build-up of fat in the liver that leads to inflammation and scarring), Encephalopathy (A group of conditions that cause brain dysfunction), Cognitive Communication Deficit ( A difficulty with communication caused by problems with cognitive functions like attention, memory, and problem-solving, not just language or speech), Other Abnormalities of Gat and Mobility (walking patterns that deviate from normal), Major Depressive Disorder, Anxiety Disorder. Review of Resident #4's quarterly MDS assessment, dated 03/01/25, revealed her BIMS score was 13 of 15 (Cognitively intact); and required supervision or touching assistance with toileting and occasional assistance with urinary incontinent care. Review of Resident #4's Care Plan, dated 3/4/25, read: I have a Self-Care deficit related to recent decline in condition: I will maintain or improve my ability to participate in my care with ADLs though my next review date. Interventions read: Hygiene: I require 1 staff assist for hygiene ADLs, Toileting/Incontinent care x 1 person assistance, Transfers: x 1 person assistance, Dressing & Grooming: x 1 person assistance. Observation on 05/13/25 at 10:15 AM revealed Resident #4's bed linen had brown residue on the right side and left side of the sheets, and there was brown residue on the right side of the resident's pillow. Observation on 05/14/25 at 11:14 AM of Resident #4's bed linen revealed the bed linen had not been changed. Interview and observation on 05/14/25 at 12:29 PM with Resident #4 revealed the resident lying in bed on the same bed linen. The resident's sheets still had not been changed. The resident reported her sheets had not been changed since last week (she could not remember the exact day that her sheets had been changed). She stated she was not sure how often the sheets were supposed to be changed, but reported she did not feel as though she should have to request for them to be changed. She stated the staff were supposed to change her sheets and make her bed, but reported it had not been done. The resident stated the residue on her sheets were chocolate. She stated the chocolate had been on her sheets since Friday of last week. Interview on 05/14/25 at 1:36 PM with CNA F revealed she checked on the residents every hour. She stated the CNAs were responsible for changing the residents' bed linen. She stated the linen was changed as needed, when they asked, and after showers. She stated the residents' shower days are every other day. She stated Resident #4's linen had not been changed. She stated she was not sure why the linen had not been changed yet. She stated the risk of the linen not being changed was bed sores or bugs, and possible infection, depending on what was on the sheet. She stated she did not change the resident bedding on yesterday. Interview on 05/14/25 at 3:38 PM with the DON revealed bed linen was expected to be changed on shower days and as needed. She stated the CNAs were expected to change bed linen when the shower techs were giving showers. She stated the risk of not changing bed linen would depend on what was in the bed. She stated she did not think there was a policy for bedding/linen changes. Interview on 05/15/25 at 3:08 PM with the Administrator revealed the CNAs were responsible for changing the residents' bed linen. She stated the resident's linen should be changed consistently with baths/showers, when soiled, wet or at the resident's request. She stated the risk of not changing linen, could cause rash as it promoted skin integrity. On 05/14/25 at 1:38 PM a facility policy for bedding/linen was requested but the Administrator reported there was no policy for bedding/linen. On 05/15/25 at 9:36 AM a facility policy for homelike environment was requested but the Administrator reported there was no policy for homelike environment.

Based on observation, interviews, and record review, the facility failed to ensure in accordance with State and Federal laws, all drugs and biologicals were stored securely in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for one (Medication Aide Cart South Station 500 (Medication Cart #1)) of five medication carts observed for storage of medications. The facility failed to ensure the Medication Cart #1 was secured when unattended. This deficient practice could place residents at risk for loss of prescribed medications, resident's safety, and drug diversion. Findings included: Observation on 05/14/2025 at 7:35 am revealed Medication Cart #1 observed unlocked and no person near cart in the 500-hall nursing station area. Interview and observation with LVN A on 05/14/2025 at 7:35 am, LVN A was notified Medication Cart #1 was unlocked, she pressed the lock. LVN A stated the medication cart should be locked when not attended, so people could not get in it, to prevent theft of medication, to prevent residents from getting medications that are not ordered for them and prevent adverse effects. Interview and observation with MA B on 05/14/2025 at 7:55 am when MA B was notified Medication Cart #1 was unlocked. MA B stated she has not been near the cart on 05/14/2025 and was unaware it was unlocked. MA B stated medication cart should be locked when not in use for the safety of residents. Interview with the Director of Nursing (DON) on 05/14/2025 at 2:00 PM, DON stated all medication carts should be locked when not in use. The risk of the medication cart not being locked was anyone can get into the cart and take something out they should not have. DON reported her plan of correction would be in-service and re-educate the staff and perform rounds several times daily to assure medication carts are locked when not in use. Interview with the Assistant Director of Nursing (ADON) on 05/15/2025 at 9:05 AM, ADON stated all medication carts should be locked when not in use. She stated the risk of the medication cart not being locked was anyone can get into the cart and take something out they should not have. ADON reported she would monitor all carts several times daily when rounding. Interview with the Administrator on 05/15/2025 at 2:45 pm, Administrator stated all medication carts should be locked when not in use. She reported the med cart should be locked by pushing the lock button in when not attended and the keys are held by the person assigned to that cart for the day. She stated the reason the cart should be locked was to keep medications secure, prevent drug diversion, resident safety, prevent resident illness, injury, or death. She reported education regarding locking medication carts is given in orientation, as needed and annually. Administrator reported she would monitor all carts several times daily when rounding. Record review of the facility's policy: Medication Cart Use & Storage Revised 2023. Compliance Guidelines: The nursing Team Members (Nurses & CMA's) use the medication cart to systematically distribute physician ordered medications to residents. RESPONSIBLE DISCIPLINES Licensed nurses, C.M.A.'s GUIDELINES 1. Security o The medication cart and its storage bins should be kept closed, secured and/or in the line of sight when not in use.

Based on observation, interview, and record review, the facility failed to ensure an infection prevention and control program designed to provide a safe, and sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 residents (Resident #195) reviewed for infection control. The facility failed to ensure intravenous tubing was stored safely with medication attached, dated, timed, initialed, and free of contamination while hanging on pole. This failure could place residents at risk of infection, worsening infection, and a decreased quality of life. Findings include: Findings included: Record review of Resident #195's, face sheet dated May 13, 2025, indicated that resident was a 52-year- old male who was initially admitted to the facility on [DATE]. Resident #195 had diagnoses which included Sepsis (is a life-threatening medical emergency caused by your body's overwhelming response to an infection), Acute Appendicitis (is a sudden and severe inflammation of the appendix). Record review of the Minimum Data Set (MDS) assessment, dated 04/19/2025, indicated that Resident #195 had moderately impaired cognition. The MDS indicated that Resident #195 needed setup or on person supervision for transferring, eating, toileting, bathing, and locomotion. Record review of the comprehensive care plan, created 04/17/2025, indicated that Resident #195 Focus: at risk for infection or recurrent/chronic infection related to compromised medical condition. Goal: will be free from signs and symptoms of infections and any complications related to infection through the review date. Interventions: Report changes in condition to MD as clinically indicated. Enhanced Barrier Precautions practices as clinically indicated. Record review of the Medication Administration Report (MAR) dated 05/01/2025-05/31/2025, indicated Resident #195 had an order for Meropenem Solution Reconstituted 1 GM to be given three times daily intravenously for infection, Mycomine Intravenous Solution Reconstituted 100 mg to be given one time daily intravenously for infection, flush with Normal Saline Flush solution before and after medications. Observation and interview on 05/13/2025 at 10:14 am with R#195 revealed used Intravenous (IV) tubing hanging from IV pole. There was no medication attached to IV tubing, no cap at the end of the line. The tubing was not dated, timed, or initialed. Resident stated he did not know why the IV tubing was hanging there like that. Observation and interview on 05/13/2025 at 10:15 am with LVN C revealed she was unaware that the IV tubing was hanging on the pole without medication or cap attached, not labeled, dated, or initialed. LVN C stated it was a potential for infection if the tubing were to be reused. Interview on 5/13/25 at 1:55 PM with the DON , revealed the process for IV infusion was to label, date and initial IV medication bag or bottle and tubing, post-infusion care to maintain sterility and patient safety. The expectation that staff should not leave unmarked tubing exposed to air is a crucial infection control measure. The DON stated in-services regarding IV services had been given to nurses during orientation, on an as needed basis, and monthly. TheDON stated her expectation is that staff will not leave unmarked tubing hanging on pole with spike open to air. Interview on 5/15/2025 at 9:05 AM with the ADON, revealed the process for IV infusion is to label, date, and initial IV medication bag or bottle and tubing, post-infusion care to maintain sterility and patient safety. She stated the expectation that staff should not leave unmarked tubing exposed to air is a crucial infection control measure. The ADON stated in-services regarding IV services have been given to nurses during orientation, on an as needed basis and monthly. The ADON expectation is that staff will not leave unmarked tubing hanging on pole with spike open to air. Interview on 5/15/2025 at 2:35 pm with the Administrator, revealed her expectation will be strict adherence to policy and procedure for IV medication administration to ensure resident safety. She stated Monitor staff compliance, provide ongoing education, and conduct observations to maintain high standards of care . Record review of -IV Policies and Procedures Manual_v3.0. indicated, Page 11 4.3.3 Dial-A-Flow Instruction for Infusion Set-Up 15. Remove the end of the medication tubing from the PIC line, making sure not to contaminate the end of the tubing, and place a red cap to cover and protect until next use. 16. Leave the IV bag attached to the tubing until the next dose is due.4.6.21 Setting Up page 22 Procedure 1. After verifying the label on IV bag matches with the prescribed order, attach the label to the tubing and bag with the date, time, and nurse's initials. 10. When the therapy is complete, disconnect from the resident's catheter and cap the tubing, and flush per facility procedure if administering medication. Record Review of IFC Infection Prevention and Control 4 2024v2 Infection Prevention and Control, revised April 2024 indicated, Compliance Guidelines: The infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program. The elements of the infection prevention and control program consist of coordination/oversight, guidance/procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety. Prevention of Infection a. Important facets of infection prevention include: (1) identifying possible infections or potential complications of existing infections; (2) instituting measures to avoid complications or dissemination; (3) educating staff and ensuring that they adhere to proper techniques and procedures; (5) educating staff and ensuring that they adhere to reporting exposures to potentially infectious materials; (6) educating staff and ensuring that they adhere to proper infection prevention and control practices when performing resident care activities as it pertains to his/her role responsibilities and situation.

Based on observation, interview, and record review the facility failed to dispose of garbage and refuse properly for 2 of 2 dumpster reviewed for food and nutrition services. 1. The facility failed to ensure doors were closed on 2 of 2 dumpsters and 1 of the 2 dumpsters had exposed bagged trash at the door's opening. This failure could place residents at risk of contact with pests and associated diseases Findings include: In an observation on 05/13/2025 at 8:20 a.m., during the Nursing Facility (NF)'s initial kitchen tour of 2 of 2 dumpsters located outside the NF, the doors were opened on both of the 2-dumpsters and 1-dumpster had exposed bagged trash at the door's opening. On both dumpster doors were signs attached that read in part Keep trash closed at all times. The Dietary Manager (DM) closed both dumpster doors immediately upon observation. During an interview on 05/13/2025 at 8:21 a.m., the DM stated that the dumpster doors were to always remain closed to maintain pest control. She stated it had been the responsibility of all that NF staff that used the dumpster to keep the doors closed. During an interview on 05/14/2025 at 03:26 p.m., the DM stated that all the department staff disposed of trash in the dumpster. She stated the importance of keeping the dumpster doors closed after use was to ensure that rodents were kept out and to maintain pest control. She stated the maintenance director's had the responsibility to initiate pest control in-services for the NF. During an interview on 05/15/2025 at 3:10 p.m., the Administrator stated that dumpster doors were to always remain closed to ensure that racoons and other critters could not get within and cause pest control issues. She stated that the NF staff received an in-service on the importance of the dumpster doors remaining closed after it was discovered during the initial kitchen tour that the door were found opened. During an interview on 05/15/2025 at 03:54 p.m., the Director of Nursing (DON) stated that it was everyone who disposed of trash in the NF dumpster to ensure the dumpster doors were closed and to conceal trash within and keep ensuring that nothing and no one got within. She stated that there were no risks to the residents if the doors had not remained closed as the residents did not dwell near the dumpsters. She stated any infestation that could occur due to failure to keep the dumpster doors closed would not affect the residents because the dumpsters were far enough away for the NF. She stated that in-services were performed all the time on proper trash disposal to include keeping the dumpster doors closed. She stated that the NF staff received an in-service on the importance of the dumpster doors remaining closed after it was discovered during the initial kitchen tour that the door were found opened. Record review on 05/13/2025 at 12:28 p.m., reflected an in-service training dated 8/16/2024 and titled Training/Retraining . After disposal of trash, please make sure trash containers are closed after every use and that all exterior doors are closed. Signed by the DM. Records request on 05/13/2025 at 08:54 a.m., for a policy on trash disposal had been asked and not received.

Based on interviews and record review, the facility failed to promote and facilitate resident self- determination through support of resident choice for 1 of 4 residents (Resident #1) reviewed for resident rights. The facility failed to promote Resident #1's self-determination by not allowing her to eat in the dining room during meal time. This failure could place residents at risk of a decreased self-worth due to their preferences not being met. The findings include: Record Review of Resident #1's face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE] with a diagnosis of Cerebral Palsy (affects the movement and posture) and hypertension (high blood pressure) and major depressive disorder (mood disorder that causes feelings of sadness). Record Review of Resident #1's MDS dated [DATE] revealed a BIMS score of 12. Resident #1 used a wheelchair or walker as a mobility device; Resident #1 used suitable utensils to eat on her own; however, set up assistance was needed. Record Review of Resident #1's care plan dated 3/26/2024 revealed Resident #1's goals were to improve her ability to care for herself and require less physical dependence on others with ADL's. In an interview with FM A on 10/9/2024 at 2:50pm she stated Resident#1 called her a week in a half ago, which was the end of September 2024 (unsure of actual day) and told her the nursing staff was refusing to allow her to eat her meal in the dining area. She stated Resident #1 stated she was told to eat at the nursing station or in her room because staff had called in sick and there was a shortage of staff. FM A stated she telephoned the facility and spoke with an unidentified nurse who confirmed the shortage and indicated for safety reasons all residents were to either eat in their room or at the table next to the nursing station. In an interview with CNA A at 4:23pm she stated she worked with Resident #1 for 4 days out of the week. She stated when there is staff shortage residents have to eat in their rooms or by the nursing station. She stated, Resident #1 had Covid in August 2024 (unsure of date) and was quarantined. She stated that being confined to her room with the door closed was difficult for Resident #1. During the quarantine, Resident #1 would have outbursts and began screaming, hollering, and yelling because Resident #1 was feeling like she was boxed in a small space. CNA A further stated that the boxed in feeling may have contributed to Resident #1 outburst regarding not being able to eat in the dining room. In an interview with Resident #1 on 10/9/2024 at 5:57pm she stated she wanted to eat in the dining room and not in her room. She stated she didn't like being in her room. She stated she liked being out in the area with other residents. She stated about two weeks ago a CNA pushed her in her wheelchair to the dining room where she got her tray of food. She stated the nurse came in the dining room and told her that they were short of staff, and she had to eat by the nurse's station or in her room. Resident #1 stated she didn't want to eat in her room, and she was okay where she was at. She stated she didn't have an issue eating or swallowing and she didn't want to sit at or near the nursing station to eat nor was she going in her room to eat. Resident #1 stated LVN A picked up her tray and tried to take it, but she held on to it. She stated during the struggle with the tray (both pulling on tray), the food dropped on the floor. She stated the nurse got mad and told her she had to go to her room. She stated the nurse pushed her to her room and had a CNA sat there with her. She stated another tray was brought to her room and she didn't want it. She stated a lot of times staff were not in the dining room, but they wanted to apply the rules that day. She stated every time a staff member called in sick the residents are required to eat in their rooms which is not fair. In an interview with LVN A on 10/9/2024 at 6:54pm revealed she worked with Resident #1 and has recently documented on her behavior issue. LVN A stated Resident#1 is a problem. She stated she spoke with the [NAME] employees who informed her that Resident #1 has a diminished mental capacity of a 5-year-old. LVN A stated about two weeks ago there was a CNA who called in sick and would not be in to work. She stated the call in made the shift short of staff and as a result nurses must be on the floor doing observation and were not available to be in the dining room for observation. During this time, resident are to eat either in their rooms or at the table located next to the nursing station. LVN A stated Resident#1 wanted to go to the dining room during that time and she told her she could choose to eat in her room or next to the nursing station. She stated Resident #1 was adamant about eating in the dining room. She stated Resident #1 convinced another CNA to bring her to dining room. LVN A stated a nursing staff must be in the dining room while residents are there. There was no one monitoring residents in the dining room. LVN A stated she went to grab the tray and Resident#1 knocked all the food items off the tray onto the floor. LVN A stated she told resident she could eat in her room, but she refused. LVN A stated if Resident #1 wanted to eat in her room, there were aides in the hall that could look in her room and monitor her, but they would not be by her bedside. LVN A stated CNA B was asked to sit with Resident #1 after she took her to her room. LVN A knew the resident was upset. In an interview with the Admin on 10/9/2024 at 7:11pm he stated if an employee called in sick for their work shift, then facility policy was to call a worker in to cover that shift PRN (as needed). He stated all residents have a right to eat in the dining area and being denied because of a staff shortage was unacceptable. He stated he was unaware of that process and did not know that Resident #1 was denied the right to eat in the dining room. In an interview with PCM on 10/10/2024 at 10:30am revealed she visited 10/8/2024, with Resident #1 and during that visit, Resident #1 was crying. She stated Resident #1 told her she was manhandled (forced back to her room by a LVN pushing her in the wheelchair) back to her room from the dining area after she refused to eat in her room because the facility was short of staff. PCM stated Resident #1 does not like to eat in her room. Resident #1 likes to eat in the dining room with other residents. In an interview with CNA B on 10/10/2024 at 2:31pm revealed about two weeks ago (couldn't remember exact date), earlier during lunch time she was caring for some residents in their rooms, and she heard Resident #1 screaming, then what appeared to be a crash. She was informed by LVN A, that Resident #1 didn't want to eat in her room and got upset and knocked the food and tray on the floor. She stated LVN A wheeled Resident#1 to her room so that she could decompress and calm down because she was screaming and disturbing the other residents. CNA B stated she has been informed and trained that when staff is not available or there is a shortage of staff, the dining room is closed, and residents are to eat in their rooms because there are no staff to observe the resident in case of an emergency. CNA B stated she brought Resident #1 a food tray from the dining room, and Resident#1 told her she wasn't going to eat what was in the tray because it wasn't what she ordered or had while in the dining room. CNA B stated Resident#1 continually stated to her that she needed to eat because she was losing a lot of weight. She stated she took the tray back, told LVN A Resident #1 didn't want to eat what was on the tray. CNA B stated LVN A didn't say anything about the tray, so she returned the tray to the dining area and there wasn't another tray given to resident after her refusal. In an interview with an anonymous resident on 10/11/2024 at 12:22pm stated if there was a staff shortage, residents are required to eat in their rooms or at the supervisor's desk area. She stated this was not an issue for her since she liked to eat in her room anyway. However, she stated she knew Resident #1 does not like to eat in her room. In an interview with Resident #3 on 10/11/2024 at 12:42pm she stated, when there is a shortage of staff because staff member calls in and stated they would not be in for their work shift, residents are required to eat in their room or in the area where the nurse station is located. She stated the residents have no other choice. She stated she didn't mine eating in her room but knows Resident #1 does not like it because she liked eating in the dining area. In an interview with CNA C on 10/11/2024 at 3:45pm revealed when the facility is short staffed sometimes residents must eat in their rooms or in the area of the nursing station so if there is an issue with choking or something then the nurses can address it immediately. She stated this is only an issue with Resident #1 because she always wants her way. Record review of the facility's Resident Rights Policy dated 2/2017 and revised 10/2022 revealed, the community should educate, encourage, and honor the rights of those we serve. The Community will promote the exercise rights for each resident, including any who face barriers (such as communication problems, hearing problems and cognition limits) in the exercise of these rights. Record Review of the facility's Quality of Life policy dated 0/2017 and revised 1/2023 revealed: Dignity - Community will promote care of residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his individuality. Self-determination and participation. Resident has a right to: C. Make choices about aspect of life in the community that are significant to them.

Based on interviews and record reviews, the facility failed to recognize the residents right to formulate an advance directive for 1 of 20 residents (Resident #264) reviewed for advanced directives. The facility failed to enter a code status (the type of emergent treatment a person would or would not receive if their heart or breathing were to stop) for Resident #264 from admission on 3/6/24 to 3/21/24. This failure could place residents at risk of not having their end of life wishes met. Findings include: Record review of Resident #264's face sheet printed 3/19/24 at 2:54pm, revealed she was a [AGE] year-old female admitted on [DATE] with diagnoses of fracture of left femur, fracture of left wrist, wedge compression fracture of lumbar vertebrae, fracture of left forearm, dyspnea (shortness of breath), acute kidney failure (kidneys are not filtering correctly), type 2 diabetes (body does not produce enough insulin), and dementia. Under Advance Directive on the care plan, it was blank. Record review of Resident #264's Entry MDS assessment dated [DATE] revealed she admitted to the facility on [DATE] from a hospital. Record review of Resident #264's BIMs score performed by the SW on 3/7/24 at 4:21pm, revealed she had severely impaired cognition. Record review of Resident #264's care plan dated 3/7/24, revealed a Focus: Resident/Family/RP does not have advanced directives and elects Full Code Status (Initiated: 3/7/24, Created: 3/7/24). Goal: Community will follow full code status (resuscitation provided when the heart stops) through review date (Initiated: 3/7/24, Created: 3/7/24, Target: 6/5/24). Interventions: Review code status at least annually and as indicated (Initiated: 3/7/24, Created: 3/7/24). Record review of Resident #264's medical record revealed a Care Plan Conference note from 3/8/24 at 11:41am from the SW. The note revealed the resident's family member decided they wanted the resident to be a full code. Record review of Resident #264's active Physician Orders by MD A on 3/19/24 at 2:52pm, revealed no orders for a code status. Record review of Resident #264's Physician Orders by MD A revealed an order from 3/21/24 at 10:23am which revealed, Full Code Clarification Order. In an interview with the SW on 3/21/24 at 9:38am, she said Staff A should have put the code status in for Resident #264 when she received the admission papers for the resident. She stated she updated the care plans once admissions entered the code status for the resident. She said the nursing staff and all staff should have caught the issue and she did not know why it was not caught. She said she would investigate the issue that she had the care plan meeting, which said the resident wanted to be full code, but nothing was entered into the chart after that. In an interview with Staff A on 3/21/24 at 9:47am, she said nursing received all the admission papers from the hospital regarding code status and entered the code status. She said she was medical records and did not receive admission papers prior to the resident coming to the facility. She said admissions would be the person who would receive the paperwork before the resident arrived. In an interview with the Admissions Director on 3/21/24 at 9:51am, she said she received all the admission papers from the hospital before residents arrived. She then filled out a paper that indicated if the resident wanted to be a full code or DNR. She said then the SW had the care plan meeting and confirmed with the family/resident if the code status was correct, or if they wanted to change it. She said after the SW confirms the code status, she updated the face sheet. As far as entering the code status order, she thought nursing was responsible for that, but she was unsure. Regarding Resident #264, she said she received admission papers that the resident wanted to be a full code and had filled out the necessary papers. She said she performed all of her job duties and it was next in the hands of the SW. In an interview with the DON on 3/21/24 at 10:16am, she said the nursing staff would have received the admission papers for Resident #264 before she arrived at the facility. The nursing staff were responsible for updating the face sheet and entering a code status on the resident. She said she was unsure of why it was not done, and she would have to talk to the nurse. She said if a code status was not entered on a resident, they would perform full code until told otherwise. Record review of the facility's policy and procedure for Advanced Directives (revised January 2023) read in part: Every resident has the right to formulate an advance directive and to refuse treatment. The community will determine the existence of an advance directive at the time of admission .The IDT will notify the medical provider of the resident's/representative's care decisions made to include expressed advance directive, such as DNR code status. The nurse should then obtain a physician's order for appropriate care decision in order to initiate and implement the preferred treatment wishes expressed .The medical record and resident plan of care should reflect the resident's wishes as well as the physician orders in order to meet the directives described.

Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights for 3 of 6 residents (Resident #24, Resident # 40, and Resident #213) reviewed for care plans. -Resident #24's care plan reflected she had a DNR status despite having orders to be full-code (desiring resuscitation if the heart stops) . -Resident #40's and Resident #213's care plans reflected they were a full-code status despite having orders and an active DNR on file. These failures could lead to confusion related to life saving measures, life saving measures being provided to a resident who had a DNR status, not providing life saving measures to a resident who had a full-code status. Findings included: Resident #24 Record review of Resident #24's face sheet dated 3/19/2024 revealed a [AGE] year-old woman admitted on [DATE]. The face sheet documented her diagnoses included spinal stenosis (condition where spinal column narrows and compresses the spinal cord), depression (mood disorder that causes a persistent feeling of sadness and loss of interest), polyneuropathy (damage to multiple peripheral nerves), scoliosis (condition characterized by sideways curvature of the spine or back bone, often noted during growth spurt just before a child attains puberty), and dementia (group of symptoms that affects memory, thinking and interferes with daily life). Record review of Resident #24's quarterly MDS assessment dated [DATE] with an ARD of 2/28/2024 revealed a BIMS score of 3 indicating severe impairment. The MDS documented she had no impairment of either her upper or lower extremities, and she used a wheelchair for mobility. Per the MDS, Resident #24 required assistance with all ADLs except eating. The MDS revealed she was not receiving hospice care services. Record review of Resident #24's care plan dated 2/22/2024 revealed a focus on her DNR status. Record review of Resident #24's physician's orders report dated 3/19/2024 revealed an order dated 1/16/2024 for her to have a full code status. Resident #40 Record review of Resident #40's face sheet dated 3/19/2024 revealed a [AGE] year-old man admitted on [DATE]. The face sheet documented his diagnoses included acute hematogenous osteomyelitis (infection in the bone caused by bacteria or fungi) of the foot and ankle, muscle wasting (loss of muscle leading to its shrinking and weakening) and atrophy (thinning of muscle mass), type 2 diabetes mellitus (condition results from insufficient production of insulin, causing high blood sugar), depression (mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (group of mental illnesses that cause constant fear and worry), neuropathy (group of diseases resulting from damaged or malfunctioning of nerves that causes weakness, numbness and pain in hands and feet), hypertension (high blood pressure), heart failure (condition in which the heart has lost the ability to pump enough blood to the body's tissues), COPD (common and treatable disease that is characterized by persistent respiratory symptoms like progressive breathlessness and cough), GERD (chronic digestive disease where the liquid content of the stomach refluxes into the esophagus, the tube connecting the mouth and stomach), diverticulitis (inflammation of the diverticula, small, bulging pouches that can form in the lining of the digestive system), benign prostatic hyperplasia (condition in which the flow of urine is blocked due to the enlargement of prostate gland), and acquired absence (amputation) of the foot. Record review of Resident #40's quarterly MDS assessment dated [DATE] revealed a BIMS score of 13, indicating no cognitive impairment. The MDS documented he had no impairment of either his upper or lower extremities, and he used a wheelchair for mobility. Per the MDS, Resident #40 required assistance with toileting, bathing, dressing his lower body, putting on and/or taking off footwear, and personal hygiene. Record review of Resident #40's care plan dated 2/15/2024 revealed a focus on his self-care deficit with interventions including assistance with bed mobility, dressing and grooming, hygiene, toileting, and transfers. The care plan revealed he did not have advanced directives in place and elected to be full code. Record review of Resident #40's DNR dated 8/31/2023 revealed it was signed by Resident #40, two witnesses, and his PCP on 8/31/2023. Record review of Resident #40's physician's orders report dated 3/19/2024 revealed an order for him to have a DNR status dated 9/8/2023. Attempted interview on 3/21/2024 at 1:24 PM with Resident #40 was unsuccessful as he refused. Attempted interview on 3/21/2024 at 3:35 PM with Resident #40 was unsuccessful as he was not in his room. Resident #213 Record review or Resident #213's face sheet revealed a [AGE] year-old woman admitted on [DATE]. The face sheet documented her diagnoses included a pelvis (basin-shaped complex of bones that connects the trunk and the legs, supports and balances the trunk, and contains and supports the intestines, the urinary bladder, and the internal sex organs) fracture (partial or complete break in a bone), fracture of the pubis (most forward-facing bone of the pelvic bones), fracture of the fourth lumbar vertebra (bone in the lower back), hypertension (high blood pressure), and dementia (group of symptoms that affects memory, thinking and interferes with daily life). Record review of Resident #213's admission MDS assessment dated [DATE] with an ARD of 2/8/2024 revealed a BIMS score of 13 indicating no cognitive impairment. The MDS documented she had no impairment of either her upper or lower extremities, and she used a wheelchair for mobility. Per the MDS, Resident #213 required assistance with all ADLs except eating and personal hygiene. Record review of Resident #213's care plan dated 3/16/2024 revealed she did not have advanced directives and elected to be full code. Record review of Resident #213's DNR form dated 3/8/2024 revealed it was signed by Resident #213, two witnesses, and the physician on 3/8/2024. Record review of Resident #213's physician's orders report dated 3/19/2024 revealed an order for her to have a DNR status. Interview on 3/21/2024 at 1:09 PM with Resident #213, she said she did not recall going over any paperwork when she first admitted to the facility. Resident #213 said she did not remember speaking to anyone about her advanced directives. Resident #213 said she would not want to have life saving measures provided if she required them. Interview on 3/21/2024 at 9:21 AM with the Corporate MDS Nurse, she said she was responsible for providing supervision to the MDS nurses at multiple facilities within the corporation. The Corporate MDS Nurse said updating the care plans was a system approach. The Corporate MDS Nurse said the nurse responsible for a specific area would update that care plan area, such as the nurse responsible for weights would update a resident's weight care plans. The Corporate MDS Nurse said advanced directives were typically completed by the social services department. The Corporate MDS Nurse said Resident #40's care plan was incorrect related to his DNR status. The corporate nurse said typically the social services director would update the care plan as soon as the DNR order was received from the resident's PCP. The corporate nurse said Resident #40's care plan documented he was a full-code resident, but he had an active DNR, had a DNR order, and the care plan should have reflected that. The Corporate MDS Nurse said care plan reflected her DNR on file, but the electronic medical record documented she was full code. The Corporate MDS Nurse said if a resident's advanced directives were incorrect it could lead to a miscommunication and staff either performing life saving measures on a resident who was DNR, or not providing life saving measures to a resident who was full code. Interview on 3/21/2024 at 9:29 AM with the SW, she said she had been employed for seven years. The SW said she was not responsible for updating resident care plans. The SW said she was not sure why Resident #40's care plan documented he had a full code status. The SW said Resident #40 had a DNR status. The SW said Resident #24 had gone to the hospital multiple times since her admission and her DNR or full code status may have been missed in the system. The SW said when a resident first admitted , if he/she did not have a DNR in place and wanted to do so she would complete it then. The SW said medical records would then send the DNR to the resident's PCP for signature. The SW said a resident would remain in full code status until the DNR order was received from the physician. Interview on 3/21/2024 at 10:09 AM with the DON, she said the facility had called Resident #24's RP on 3/21/2024 and the family member was confused on what a DNR entailed. The DON said Resident #24 had gone to the hospital three times since her initial DNR was put in place, and that Resident #24's RP did not understand what the difference between DNR and full code status was. The DON said Resident #24's RP had requested the facility call her prior to any life saving measures, or to send her to the hospital for life saving measures. The DON said Resident #24's RP agreed to have Resident #24 have a full code status. The DON said Resident #24's care plan was incorrect. The DON said if a resident did not have any documentation in the DNR binder, that resident was in a full code status. The DON said the facility would perform life saving measures for any resident who was full code status. The DON said the facility would complete an audit to ensure all the residents' care plans were correct regarding their advanced directives. The DON said if the resident's care plan was incorrect and noted he/she was in a full code status, the facility may begin life saving measures, but that would not be as concerning as not providing life saving measures to a resident who had a full code status. The DON said if the facility did not initiate life saving measures for a resident with a full code status, that resident could die. Interview on 3/21/2024 at 2:40 PM with the ADON, she said she had been employed since December of 2023. The ADON said her primary duties included caring for residents, advocating for residents, ensuring they were well cared for, medication administration, and assistance with ADLs. The ADON said care plans were put in place to identify a resident's care needs. The ADON said the care plans were instructions on how to care for a resident. The ADON said she would review the care plans when she had a concern for a resident. The ADON said if there were two different instructions in the care plan versus the physician's orders, she would look at order first. The ADON said if a resident was wrongly identified as having a full code status and life saving measures were provided to a resident with a DNR status, the facility or staff could be liable for damages. Interview on 3/21/2024 at 2:59 PM with the WCN, she said he had been employed since December 7, 2023. The WCN said her primary duties were to care for the residents' wounds in the building. The WCN said she was the facility's wound care nurse. The WCN said the residents' care plans provided a plan of care, or how to care for a resident at the facility. If a care plan was incorrect the resident may not receive the care he/she required. Interview on 3/21/2024 at 3:59 PM with the Admin, he said he had been employed since February 2023. The admin said his expectations related to residents' care plans were that they would ideally be completed by the IDT system. The Admin said in past communities he was employed at, the facilities would complete generalized resident care plans. The Admin said he would like for the facility to create more individualized resident care plans. The Admin said resident care plans were reviewed during the morning meetings and were completed as the IDT was able during those meetings. The Admin said his expectations for resident care plans was that they were individualized. The Admin said if a care plan did not match a resident's physician's orders, the resident may not be provided care as was ordered. The Admin said the facility ensured the physician's orders were reflected in the electronic medical record first, and then the facility would update the resident's care plan. Record review of the facility's Code Status binder revealed Resident #40's DNR was present, Resident #213's DNR was present, and Resident #24 did not have a DNR present. The binder had a list of all residents with a DNR status. Resident #40 and Resident #213 were identified as having a DNR in place, but Resident #24 was not. Record review of the facility's Care Plans policy dated February 2023 revealed a policy statement which read in part .The community develops a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment . The policy documented the care plan would include any services that would not be provided due to the resident's exercise of rights, including the right to refuse treatment. Per the policy, residents had the right to refuse specific treatments. The policy noted the care plan would be updated within seven days of the completion of the comprehensive assessment. Record review of the facility's Advanced Directives policy dated January 2023 revealed a policy statement which read Every resident has the right to formulate an advance directive and to refuse treatment. The community will determine the existence of an advance directive at the time of admission. The policy documented that a resident's medical record and resident plan of care should reflect the resident's wishes as well as the physician orders.

Based on observations, interviews, and record reviews, the facility failed to ensure residents who were unable to carry out activities of daily living were provided with the necessary services to maintain good personal hygiene for 1 of 20 (Resident #48) residents sampled for ADL care. -The facility failed to provide Resident #42 with a specialized call bell between 3/19/24 and 3/21/24. -The facility failed to shower and dress Resident #42 in his own clothes between 3/19/24 and 3/21/4. -The facility failed to get Resident #42 up out of bed between 3/19/24 and 3/21/24. These failures could place residents who are dependent on staff for ADLs, at risk of not receiving personal hygiene, experiencing a delay in receiving necessary careb. Findings included: Record review of Resident #42's undated face sheet revealed he was a [AGE] year-old male admitted on [DATE] with an original admitted [DATE]. He had diagnoses of anoxic brain damage (brain damage from lack of oxygen), chronic heart failure (heart does not pump strongly), gastrostomy (tube into stomach for nutrition), dysphagia (unable to swallow), aphasia (unable to talk), hypertension (high blood pressure), GERD, duodenal ulcer (ulcer in the small intestine), and muscle weakness. Record review of Resident #42's Annual MDS assessment dated [DATE], revealed a BIMS was not able to be conducted. The staff assessment for mental status revealed the resident had severely impaired cognition. The resident had impairment on both sides of his upper and lower extremities. According to the MDS, the resident was dependent with all ADLs. The resident was high risk for pressure ulcers/injuries but did not have any. The MDS revealed he was receiving applications of ointments/medications other than to feet and applications of nonsurgical dressings other than to feet. He was receiving tracheostomy care while a resident. Record review of Resident #42's care plan dated 2/13/20, revealed a Focus: Resident to use Geri Chair when out of bed d/t poor trunk control (Initiated: 8/2/21, Created: 8/2/21, Revised: 4/16/22). Goal: Resident to tolerate Geri chair through next review date (Initiated: 8/2/21, Created: 8/2/21, Revised: 1/17/24). Interventions: Staff to monitor resident for safety while in Geri chair. Staff to place resident in Geri chair when out of bed for safety. Focus: The resident uses a specialized call light: Blow light (Initiated: 1/20/21, Created: 1/20/21, Revised: 1/20/21). Goal: Resident will be able to utilize my call light without noted decline; to alert care providers of my needs and wants through my next review date (Initiated: 1/20/21, Created: 1/20/21, Revised: 1/17/24). Interventions: Provide a whistle - mouth blow type call light. Round regularly to ensure needs are met. Focus: I have a self care deficit r/t cognitive impairment, poor physical functioning, incontinent of bowel and bladder (Initiated: 6/29/23, Created: 12/30/21, Revised: 6/29/23). Goal: I will maintain or improve my ability to participate in my care with ADLs through my next review date (Initiated: 12/30/21, Created: 12/30/21, Revised: 1/17/24). Interventions: Bathing/showering schedule: I prefer to be showered 2-3 times weekly & as needed. Bathing/showering care: x 2 person assistance. Bed mobility: x 2 person assistance. Dressing & grooming: x 2 person assistance. Hygiene: I require 1 staff assist for hygiene ADLs. Off-loading device: I use pressure relieving boots/devices as indicated. Toileting/incontinent care x 2 person assistance. Total lift sling size: Large/green. Total lift x 2 team members. Transfers: x 2 person assistance with Hoyer Lift. Turning & Repositioning: On rounds and as needed. Focus: The resident has a potential to skin integrity r/t needing assistance with bed mobility and incontinence of bowel and bladder (Initiated: 2/27/20, Created: 2/27/20, Revised: 2/27/20). Goal: Resident will be free from injury to skin through the review date (Initiated: 2/27/20, Created: 2/27/20, Revised: 1/17/24). Interventions: Keep skin clean and dry. Use lotion on dry skin. Record review of Resident #42's Physician Orders revealed the following orders from MD A: -Heel protectors or float heels on pillow while in bed, every shift. Ordered on 7/23/23. -The patient out of bed can be in a Geri chair. Ordered on 9/14/21. In an observation of Resident #42 on 3/19/24 at 1:44pm, the resident was laying flat on his back in bed. He was in a patient gown, was not shaved, and his hair looked greasy. He had a regular call bell pinned to the sheets and his feet were not in heel protectors or floated on pillows. In an observation of Resident #42 on 3/20/24 at 10:16am, he was laying flat on his back in bed. He had a patient gown on, was not shaved, and his hair looked greasy. He had a regular call bell pinned to the sheets and his feet were not in heel protectors or floated on pillows. In an interview with Resident #42's family member on 3/20/24 at 10:20am, she said she would come to the facility every weekend to see him. When she came, he would not be shaved, bathed, his hair was greasy, and his ears were dirty. She said she would have to clean him every weekend when she came. She said she has not been able to come for a couple months due to being sick. In an observation of Resident #42 on 3/20/24 at 3:21pm, he was laying flat on his back in bed. He had a patient gown on, was not shaved, and had greasy looking hair. He also had a regular call bell instead of a special one and his feet were not in heel protectors or floated on pillows. In an observation and interview of Resident #42 on 3/20/24 at 3:21pm, he was laying flat on his back in bed. He had a patient gown on, was not shaved, and had greasy looking hair. He also had a regular call bell instead of a special one and his feet were not in heel protectors or floated on pillows. The DON said she did not know why he was not shaved or had his special call bell. She said he would be cleaned up for tomorrow. In an observation of Resident #42 on 3/21/24 at 11:05am, he was up in a Geri chair in the activity room. He had heel protectors on, was shaved, had clean hair, and was in his normal clothes. In an interview with LVN C on 3/21/24 at 11:10am, she said she had given Resident #42 a bed bath a few days before and did not know why he was not shaved or up in his Geri chair. In an interview with the DON on 3/21/24 at 1:30pm, she said she ensured the staff were implementing the resident's interventions by making rounds throughout the day. She said the ADON and the floor nurses made rounds as well to ensure the interventions were in place. Record review of the facility's policy and procedure on Routine Resident Care (revised January 2023) read in part: Residents should receive the necessary assistance to maintain good grooming and personal/oral hygiene. Steps are taken to provide that a resident's capacity for self-performance of these activities does not diminish unless circumstances of the resident's clinical condition demonstrate the decline is unavoidable. Care is taken to maintain resident safety at all times. Licensed nurses and non-licensed direct care team members: .Showers, tub baths, and/or shampoos should be scheduled at least twice weekly and more often as needed or per residents' preferences .Daily personal hygiene minimally includes assisting .with washing their faces and hands and combing their hair. Residents should be encouraged or assisted to dress in appropriate clothing daily .Specific types of call lights, i.e. call light pads etc. should be added to the resident plan of care based upon residents abilities and limitations .

Based on observation, interview, and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (Resident #42) of 20 residents reviewed for quality of care. - The facility failed to treat Resident #42's wounds to his shins with available ointment that was prescribed. - The facility failed to treat Resident #42's tracheostomy stoma as directed by the Physician Orders. This failure could place residents at risk for diminished quality of care, pain, infection, and worsening conditions. Findings included: Record review of Resident #42's undated face sheet revealed he was a [AGE] year-old male admitted on [DATE] with an original admitted [DATE]. He had diagnoses of anoxic brain damage (brain damage from lack of oxygen), chronic heart failure (heart does not pump strongly), gastrostomy (tube into stomach for nutrition), dysphagia (unable to swallow), aphasia (unable to talk), hypertension (high blood pressure), GERD, duodenal ulcer (ulcer in the small intestine), and muscle weakness. Record review of Resident #42's Annual MDS assessment dated [DATE], revealed a BIMS was not able to be conducted. The staff assessment for mental status revealed the resident had severely impaired cognition. The resident had impairment on both sides of his upper and lower extremities. According to the MDS, the resident was dependent with all ADLs. The resident was high risk for pressure ulcers/injuries but did not have any. The MDS revealed he was receiving applications of ointments/medications other than to feet and applications of nonsurgical dressings other than to feet. He was receiving tracheostomy care while a resident. Record review of Resident #42's care plan dated 2/13/20, revealed a Focus: Resident has an old tracheostomy site which requires daily dressing changes (Initiated: 8/26/22, Created: 9/17/22, Revised: 9/17/22). Goal: Will have no s/sx of infection through the review date (Initiated: 8/26/22, Created: 9/17/22, Revised: 1/17/24). Interventions: Treatment as ordered. Focus: I have risk for complications r/t tracheostomy stoma (opening where tube into throat was) site causing a risk for complications or SOB (Initiated: 12/30/21, Created: 12/30/21, Revised: 4/16/22). Goal: I will have clear and equal breath sounds bilaterally through the review date (Initiated: 12/30/21, Created: 12/30/21, Revised: 1/17/24). Interventions: Provide good oral care daily and PRN. Focus: Resident has a potential for alteration in skin integrity r/t friction, immobility, and contractures (Initiated: 10/18/22, Created: 10/18/22, Revised: 10/18/22). Goal: I will maintain skin integrity through next review date (Initiated: 10/18/22, Created: 10/18/22, Revised: 1/17/24). Interventions: Observe skin while providing care, report to nurse any skin concerns noted. Take extra care when transferring, skin is fragile, use palms of hands for support when able. Record review of Resident #42's Skin and Wound Evaluation from 2/20/24 at 3:03pm, revealed the resident had a surgical incision that was present on admission and was healed. There was no mention of the wounds to both of his shins. Record review of Resident #42's progress notes revealed a note from 3/10/24 at 7:57pm from NP A which said, Cleanse trach stoma site with SNS and cotton swabs. Dry the site and cover with gauze and tape. Monitor s/s of infection and skin integrity. Record review of Resident #42's Skin & Wound-Total Body Skin Assessment from 3/12/24 at 6:40pm, revealed there were no wounds. Record review of Resident #42's Skin & Wound-Total Body Skin Assessment from 3/19/24 at 11:56pm, revealed there were no wounds. Record review of Resident #42's Physician Orders revealed the following orders from MD A: - Cleanse trach stoma site with SNS and cotton swabs. Dry stoma site with dry 4x4 gauze. Cover with gauze and tape, Every night shift. Ordered on 7/6/23. - Complete the Skin & Wound-Total Body Skin Assessment, Every night shift, every Tue for skin integrity. Ordered on 12/13/23. - Hydrocortisone Gel 1% Apply to affected areas, chest/leg topically as needed for rash/redness. Ordered 3/14/22. - Hydrocortisone Gel 1%, Apply to bilat legs/redness topically BID for redness for 14 days. Ordered on 3/20/24. Record review of Resident #42's February 2024 MAR-TAR revealed he did not receive the Hydrocortisone Gel 1% at all throughout February 2024. Record review of Resident #42's March 2024 MAR-TAR revealed it was documented that the resident received trach stoma site care from 3/14/24 to 3/20/24. The March 2024 MAR-TAR revealed the resident did not receive the Hydrocortisone Gel 1% at all from 3/14/24 to 3/20/24. Record review of Resident #42's progress notes revealed a note from the DON on 3/20/24 at 9:15pm which said, Spoke w/ NP n/o for hydrocortisone cream x 7 days/prn n/o initiated will cont to monitor. In an observation of Resident #42 on 3/19/24 at 1:44pm, he was laying on his back in bed. The resident's trach stoma was uncovered and did not have the ordered gauze on it. In an observation of Resident #42 on 3/20/24 at 10:16am, he was laying on his back in bed. The resident's trach stoma was uncovered and did not have the ordered gauze on it. In an observation of Resident #42 on 3/20/24 at 3:21pm, he was laying on his back in bed. He had deep red excoriations on both shins, from below his knee down to his ankles. In an observation and interview of Resident #42 on 3/20/24 at 4:21pm, he was laying on his back in bed. The DON observed the excoriations on the resident's shins and said the resident had a cream the nurses were using to treat it. She did not know why his trach stoma was not covered. In an observation of Resident #42 on 3/21/24 at 11:05am, he was up in a Geri chair in the activity room. The resident had his heel protectors on, and his trach stoma was covered and clean. In an interview with LVN C on 3/21/24 at 11:10AM, she said she did not see any redness or problems to Resident #42's legs and did not apply any creams to them. In an interview with the DON on 3/21/24 at 1:30pm, she said the nurses were applying the oily barrier cream instead of the steroid cream because they thought it would be better for the wounds. Record review of the facility's policy and procedure on Professional Standard of Care (revised February 2017) read in part: The community provides services that meet professional standards of quality and are provided by appropriately qualified persons (e.g., licensed, certified). Record review of the facility's policy and procedure on Medication Administration (revised January 2023) read in part: Resident medications are administered in an accurate, safe, timely, and sanitary manner .Verify the medication label against the medication sheet for accuracy of drug frequency, duration, strength, and route .Administer medications as ordered by the physician .Initial the electronic administration record after the medication is administered to the resident. Record review of the facility's policy and procedure on Skin and Wound Prevention and Management (revised January 2023) read in part: .At times skin failure may occur; however, the community will ensure that a resident admitting into the community will evaluated and identify the associated risks that may result in with skin breakdown .Thus, a plan of care will be developed and implemented based on the identified needs, associated risks, and current skin conditions. Each resident will receive the care and services necessary to retain or regain optimal skin integrity .Identity early onset skin breakdown so that the IDT may implement appropriate interventions as clinically indicated. Implement interventions designed to stabilize, reduce, or remove underlying risk factors. Ongoing evaluation of the plan of care and modifying or changing interventions as appropriate .The community adopts treatment protocols for the prevention, identification, assessment, and management of skin conditions, wounds, and pressure ulcer injuries .Assessment of a resident's skin condition helps determine prevention strategies. The skin assessment includes an evaluation of skin integrity. The assessment includes documentation of current pressure areas and areas of other interruption of skin integrity other than pressure. Resident's skin should be assessed/evaluated upon admission/re-admission and as clinically indicated. Clinical team members should regularly inspect each resident's skin to identify new skin concerns. A licensed nurse should at least weekly conduct a routine skin assessment/evaluation in order to identify new pressure injuries or other types of skin concerns. The licensed nurse should document the results of weekly skin checks in the resident's medical record .The licensed nurse should document the wound presentation or description of skin issue identified within the electronic health record .The licensed nurse will continue to monitor the status and progress of the wound until resolved. Should the wound deteriorate, the nurse should notify the MD/NP/PA, IDT and resident or representative of the change in condition and document the wound assessment/evaluation findings, notifications, new orders and additional interventions. Thus, the plan of care should be reviewed and updated accordingly. The nurse should continue to monitor the status of the wound and response of the treatment and interventions implemented for effectiveness and collaborate with the IDT and MD/NP/PA for any updates or concerns as identified .