Every finding on record at The Pavilion at Crescent Lake

Based on record review and interview, the facility failed to ensure the physician(s) wrote a reason for disagreement with the Resident Pharmacist Recommendations for 5 of 5 residents, Residents #2, #6, #8, #10, and #26. Findings include: Review of Resident #6's Pharmacist Recommendation dated 9/22/25 read, recommended spacing dosing of hydrocodone and valium. The physician checked disagreed and continued both medications, no reason for the decision was documented. Review of Resident #6's Pharmacist Recommendations dated 6/30/25 and 8/9/25 read, This resident is currently taking Diazepam 10 mg [milligrams] HS [hour of sleep] for anxiety. Literature indicates the maximum recommended dose for geriatric residents is 5mg/daily. Please consider re-evaluating current treatment to determine if medication is at lowest effective dose. The physician checked disagreed and continued both medications, no reason for the decision was documented. Review of the Interim Medication Regimen Review for Resident #2, dated 7/31/2025 read, Please assess risk vs. (versus) benefit on the use of the following medications based on Drug/Drug, Drug/Food, Drug/Disease, Drug/Allergy interactions – Eliquis (a blood thinner) + (plus) Aspirin: Aspirin may enhance the adverse/toxic effect of Eliquis (Apixaban). Specifically, the risk of bleeding may be increased. Monitor patients closely for signs and symptoms of bleeding with any concurrent use. The option selected by the physician was, Disagree. In the section, Physician Summary: Please indicate that the appropriate action was taken on all the aforementioned recommendations, there was nothing documented. It was signed by Physician #1 and dated 8/01/2025. Review of the Interim Medication Regimen for Resident #2 dated 9/02/2025 read, Consultant Pharmacist Recommendation to Physician: Per state and federal regulations, suggest that there is an diagnosis/indication listed on the POFs/MARs (Medication Administration Record) for each of the medications prescribed: Aripiprazole (antipsychotic): current diagnosis may not be approved at time of survey; suggest the following FDA approved dx for this medication: bipolar, mania, schizophrenia, depression associated with bipolar d/o (disorder) major depressive disorder. The option checked was disagree. Please assess risk vs. benefit of the use of the following medications based on Drug/Drug, Drug/Food, Drug/Disease, Drug/Allergy interactions: Amiodarone + Lexapro (an antidepressant medication): consider therapy modification. QT (refers to the QT interval, a crucial measurement on an electrocardiogram), indicating electrical recovery between beats -prolonging Agents may enhance the QTc-prolonging effect (increasing the risk of a dangerous, chaotic heart rhythm, which can cause fainting, seizures, and sudden cardiac death) of Escitalopram. If use is necessary, monitor for QTc interval prolongation and arrhythmias (an irregular heartbeat). The option checked was, Disagree, and Please assess risk vs. benefit on the use of the following medications based on Drug/Drug, Drug/Food, Drug/Disease, Drug/Allergy interactions - Eliquis + Aspirin: Aspirin may enhance the adverse/toxic effect of Eliquis (Apixaban). Specifically, the risk of bleeding may be increased. Monitor patients closely for signs and symptoms of bleeding with any concurrent use. The option checked was, Disagree. It was signed by Physician #1 and dated 9/05/2025. There was no reason documented by the physician/provider. Review of the Interim Medication Regimen for Resident #2 dated 10/01/2025 read, Consultant Pharmacist Recommendation to Physician: The following medication are best administered within these guidelines: Fluticasone-Salmeterol: rinse mouth with water after use, do not swallow, the option checked was, Disagree, and Please assess risk vs. benefit of the use of the following medications based on Drug/Drug, Drug/Food, Drug/Disease, Drug/Allergy interactions: Amiodarone + Lexapro: Per Lexicomp: consider therapy modification. QT-prolonging Agents may enhance the QTc-prolonging effect of Escitalopram. If use is necessary, monitor for QTc interval prolongation and arrhythmias (including torsades de pointes). The option checked was, Disagree, and Please assess risk vs. benefit on the use of the following medications based on Drug/Drug, Drug/Food, Drug/Disease, Drug/Allergy interactions - Eliquis + Aspirin: Aspirin may enhance the adverse/toxic effect of Eliquis (Apixaban). Specifically, the risk of bleeding may be increased. Monitor patients closely for signs and symptoms of bleeding with any concurrent use. The option selected by the physician was, Disagree. The form was signed by Physician #1 and dated 10/03/2025. There were no comments or explanations for declination written. Review of the Consultant Pharmacist Recommendations to Nursing Staff for Resident #2 dated 10/16/2025 read, MRR Date: 10/11/2025; Routing: Nursing - This resident is receiving the corticosteroid inhaler Advair. Please be sure to include in the plan of care that we're monitoring for throat irritation and oral thrush. Review of the Interim Medication Regimen for Resident #2 dated 11/03/2025 read, Consultant Pharmacist Recommendation to Physician: The following medication are best administered within these guidelines: Advair (Fluticasone-Salmeterol Aerosol Powder Breath Activated): Administration Instruction for Nursing: Rinse mouth after use; do not swallow, the option checked was, Disagree, and Please assess risk vs. benefit of the use of the following medications based on Drug/Drug, Drug/Food, Drug/Disease, Drug/Allergy interactions: Amiodarone + Lexapro: Per Lexicomp: consider therapy modification. QT-prolonging Agents may enhance the QTc-prolonging effect of Escitalopram. If use is necessary, monitor for QTc interval prolongation and arrhythmias (including torsades de pointes). Eliquis + Aspirin: Aspirin may enhance the adverse/toxic effect of Eliquis (Apixaban). Specifically, the risk of bleeding may be increased. Monitor patients closely for signs and symptoms of bleeding with any concurrent use. The options checked were both Disagree. The form was signed by the previous Medical Director and dated 11/05/2025. There were no comments or explanations for declination written. During an interview on 1/06/2026 at approximately 3:00 PM the DON stated that she did not know why [Physician #1's name] did not check agree, or defer to cardiology since the resident was being seen by them [cardiology]. During an interview on 1/072026 at 8:30 AM the DON stated that she was unable to locate any progress notes or physician explanation for declination of the multiple pharmacist recommendations for Resident #2. Regarding the one pharmacist recommendation directed to nursing, for Resident #2 to rinse her mouth after administration of Advair, she stated that she remembered entering the recommendation information somewhere but had not been able to locate it on her (the resident's) orders or associated with the MAR (Medication Administration Record). During an interview on 1/08/2026 at 12:45 PM Physician #1 stated that he did receive the forms with the pharmacist's recommendations, he reviewed and signed them. He usually does not disagree with the pharmacist's recommendations, but if he did disagree, he did not write a comment or explanation on the form. Review of the policy and procedure titled, Medication Regimen Reviews, with the last review date of 1/22/2025, read, Policy Statement: The consultant pharmacist reviews the medication regimen of each resident at least monthly. Policy Interpretation and Implementation: 4. The goal of the MRR (Medication Regimen Review) is to promote positive outcomes while minimizing adverse consequences and potential risks associated with medication. 8. Within 24 hours of the MRR, the consultant pharmacist provides a written report to the attending physicians for each resident identified as having a non-life-threatening medication irregularity. The report contains: a. the resident's name; b. the name of the medication; c. the identified irregularity; and d. the pharmacist's recommendation. 12. The attending physician documents in the medical record that the irregularity has been reviewed and what (if any) action was taken to address it. Review of Resident #10's Consultant Pharmacist Recommendations to Physician dated 9/22/2025 read, Recommendation: Consider dose reduction for Haloperidol to TID [three times a day] could possibly and potentially contribute to the falls episodes by causing syncope, orthostatic. Hypotension, dizziness and drowsiness. The Provider checked disagree and signed the form on 9/23/2025. The Physician did not provide a rationale. Review of Resident #26's Consultant Pharmacist Recommendations to Physician dated 8/9/2025 read, CMS Regulation. Per CMS guidelines, recommend reassessment of Phenergan 25 mg q 6 hr PRN [25 milligrams every 6 hours as needed after 14-day]. The Provider checked disagree and signed on 8/11/2025 but did not provide a rationale. Review of Resident #26 Consultant Pharmacist Recommendations to Physician dated 12/20/2025 read, Meds [medications]: Trazadone: Adverse Reactions (AR): Dizziness (20-28%), Drowsiness (24-41%), Fatigue (6-11%). Depakote AR: Dizziness (12-25%), Drowsiness (7-30%). Tamsulosin: AR: Dizziness (15-17%), Athenia (8-9%), Drowsiness (3-4^), Blurred Vision (<= 2%), hypotension) Metformin AR Dizziness (1-10%). Phenergan: sedated state, fatigue, blurred vision (Frequency not defined) Recommendations Change time of administrator for Tamsulosin to evening or bedtime. Consider dose reduction for Trazadone to 100mg HS. The Provider checked disagree and signed on 12/31/2025 but did not provide a rationale. Review of Resident #8's Consultant Pharmacist Recommendations to Physician dated 8/22/2025 read, Consider dose reduction for Trazodone to 25 mg HS [25 milligrams at bedtime]. Consider dose reduction for Gabapentin to BID [twice a day]. The Provider checked disagree and signed on 8/25/2025 but did not provide a rationale. Review of Resident #8's Consultant Pharmacist Recommendations to Physician dated 10/24/2025 read, Recommendations: Consider dose reduction for bedtime Seroquel 75mg HS [75 milligrams at bedtime]. Consider frequency reduction for Gabapentin to 100 mg q 12 hr [100 milligrams every 12 hours]. The Provider checked disagree and signed on 10/30/2025 but did not provide a rationale. During an interview on 1/8/2025 at 9:40 AM the Director of Nursing (DON) confirmed [Residents #2, #6, #8, #10, and #26] pharmacy recommendations did not include a rationale. The DON stated, Those recommendations were signed by the old doctor. Normally we do not expect to see a rationale included when the physician disagrees with the pharmacy recommendations because they are just recommendations.

Based on observation, interview, and record review the facility failed to ensure residents had a clean, homelike environment. Findings include: During an observation on 1/5/2026 at 10:12 AM Resident #76's bathroom on the left-hand side toward the bottom corner of the door was rusted and metal portions of the door frame were exposed and extended outward. (Photographic evidence obtained) During an observation on 1/5/2026 at 10:15 AM Resident #58's room wall where the sink is located has peeling paint and drywall exposed with holes. (Photographic evidence obtained) Review of Administrator's monthly walk through dated 9/22/2025 read, [Resident #58's room] holes by soap dispenser. Review of Administrator's monthly walk through dated 10/15/2025 read, [Resident #58's room] holes by soap dispenser. During an interview on 1/7/2026 at 3:10 PM the Administrator stated, I do monthly checks go into every room unless the door is closed. I was aware of certain repairs needed and I got with maintenance and told them it needs to be corrected. During an interview on 1/7/2026 at 3:45 PM the Maintenance Director stated, We were aware the dry wall in the room [Resident #58] needed to be repaired. The bathroom door frame in [Resident #76's name] room also needs to be repaired. We have not gotten to them yet it is only us two [Maintenance Assistants]. During an interview on 1/7/2026 at 3:46 PM the Maintenance Assistant stated, We have a list of repairs these [Resident #58 and #76's rooms] are listed on the list; just have not gotten to do them. During an interview on 1/05/2026 at approximately 10:55 AM Resident #81's spouse stated that he was concerned about the condition of the building. He asked this surveyor to look at the wall under the sink and especially in Resident #81's bathroom. He would like to see more attention paid to the repair of the building, even though it was an older building. During an observation on 1/05/2026 at 10:55 AM the wall under the sink in Resident #81's room was discolored a light brown color, and there was drywall or plaster missing from the wall. The shared bathroom had a brown, triangular shaped area on the wall behind the toilet, that was discolored a dark brown color. The wall and tile in the shower area there was discolored with a blackish substance, especially around the bottom edges of the floor and on the cord for the emergency call light. The air conditioning unit next to Resident #81's bed had silver tape around the edges of the unit against the wall. There were some gaps observed in the tape. (Photographic evidence obtained) During an interview on 1/07/2026 at 3:05 PM the Maintenance Director stated that there had been a leak from the sink behind the wall in [Resident #81 name's room], under the sink. It just needed to be sanded and painted. In the bathroom, we need to re-do the wall where there had been a leak behind the toilet. Review of the rounding log from 1/17/2025 documented maintenance issues identified for Resident #81's room. The comments/follow-up for the room read, Paint under sink, and Door frame. Review of the policy and procedure titled, Maintenance Service, last reviewed on 1/22/2025 read, Policy Statement: Maintenance service shall be provided to all areas of the building, grounds, and equipment. Policy Interpretation and Implementation: 1. The maintenance department is responsible for maintaining the building, grounds, and equipment in a safe and operable manner at all times. 2. Functions of maintenance personnel include, but are not limited to: b. maintaining the building in good repair and free from hazards. d. maintaining the heat/cooling system and emergency generator in good working order.

Based on interview and record review, the facility failed to ensure each resident received an accurate assessment reflective of the resident status for 3 of 9 residents, Residents #2, #9, and #35. Findings include: Review of the facility policy and procedure titled Resident MDS [Minimum Data Set] Assessment and Care Planning Policy with a last review date of 1/22/2025 read, Purpose: To provide interdisciplinary observation and assessment to ensure the most accurate assessment of resident functional capacity. Review of Resident #9 Minimum Data Set titled, Quarterly dated 10/21/2025 documented in Section I Diagnosis did not include psychotic disorder or delusion disorder. Review of Resident #9's admission record documented the resident was admitted to the facility on [DATE] with diagnosis to include delusional disorders (onset on 5/18/2023) and psychotic disorder with delusions (onset on 2/1/2024). Review of Resident #9's [Name of mental health provider] note dated 12/18/2025 read, History of Present Illness: Patient was admitted on [DATE] due to hyperlipidemia, unspecified. Allergic to ACE [Angiotensin-Converting Enzyme] inhibitors. She has a Psych HX [History] of dementia, depression, delusional disorders, psychotic disorder and a medical HX of cognitive communication deficit, muscle weakness, HTN [hypertension]. During an interview on 1/8/2026 at 10:03 AM the MDS Coordinator stated, It will have to be modified [Resident #9's name] MDS since she does have a diagnosis of psychotic disorder and delusional disorders. Review of Resident #2's MDS Assessment, a quarterly assessment, dated 11/05/2025 documented the resident has a BIMS (Brief Interview for Mental Status) Score of 15 out of 15, meaning she was cognitively intact. The special treatments and programs she was utilizing were oxygen therapy and tracheostomy care. There was a no, documented for suctioning. Review of Resident #2's Census data revealed she was initially admitted to the facility on [DATE] with medical diagnoses to include chronic obstructive pulmonary disease, unspecified; heart failure, unspecified; Type 2 diabetes mellitus without complications; anxiety disorder, unspecified; tracheostomy status; dependence on supplemental oxygen; paroxysmal atrial fibrillation Review of Resident #2's Care Plan documented a focus of, [Resident #2's name] has a tracheostomy and she does her own trach care including suctioning. [Resident #2's name] administers her own nebulizer treatments. [Resident #2's name] has continuous oxygen. Date Initiated: 09/03/2025 Revision on: 01/06/2026 Review of Resident #2's physician orders dated 1/02/2026 read, Resident may do self Trach/care and Neb treatment R/T [related to] demonstrate proper techniques. All Trach-care or orders for trach, oxygen and suction. During an interview on 1/07/2026 at 11:05 AM the MDS RN (Registered Nurse) stated, I don't know why [Resident #2's name] had no marked for suctioning. She [MDS staff] knew that the resident had a tracheostomy and used suctioning. It did not make sense that she would have made that faux pas [a French term meaning a blunder]. She [MDS staff] utilized the RAI [Resident Assessment Instrument] to guide the MDS assessments. She [MDS staff] was responsible for the section regarding special treatment such as suctioning. Review of Resident #35's admission Data documented she was admitted on [DATE] with medical diagnoses to include nondisplaced fracture of lateral condyle of left tibia, subsequent encounter for closed fracture with routine healing; generalized anxiety disorder; type 2 diabetes mellitus without complications; acute kidney failure with tubular necrosis; end stage renal disease. Review of Resident #35's MDS Assessment, a Significant Change, dated 12/24/2025 documented that she had a BIMS score of 15 out of 15, meaning she was cognitively intact; that she had limitations in range of motion on both sides of her lower extremities (her legs), was dependent of others for her mobility an all of her care except needing only set-up/clean-up assistance for eating. She was always incontinent of urine and frequently incontinent of bowels. In the section focused on documenting a resident's health issues, aiming to capture a holistic view of their well-being, she was assessed as not having a condition or chronic disease that may result in a life expectancy of less than 6 months [to live]. For special treatments or programs, it was documented that she was receiving hospice care. Review of Resident #35's Care Plan documented, Focus: [Resident #35's name] is on hospice care with [name of local] Hospice. Dx: [diagnosis] Acute Kidney Injury. Initiated: 12/18/2025; Revision on: 12/18/2025. Focus: [Resident #35's name] has renal insufficiency r/t [related to] ESRD [end stage renal disease] She does not wish to have dialysis. Date initiated: 12/29/2025; Revision on: 12/29/2025. Review of Resident #35's physician orders documented dated 12/19/2025 read, Admit to [name of local hospice company] Hospice r/t acute kidney injury. Review of the binder titled, [name of local hospice] documented Hospice IDG (interdisciplinary group) Comprehensive Assessment and Plan of Care dated 12/12/2025 and a Hospice Certification and Plan of Care dated 12/12/2025. The diagnosis documented for admission to hospice and certification of terminal illness was acute kidney failure with tubular necrosis. Resident #35's imminence of death was documented as < (less than) 6 months. During an interview on 1/07/2026 at 4:10 PM the DON (Director of Nursing) stated the prognosis or imminence of death for a resident admitted to hospice was usually 6 months or less. She was not aware that Resident #35's recent MDS (Minimum Data Set) Assessment did not document her prognosis as 6 months. The expectation was that the MDS [nurse] would review the documentation and correctly enter the information in the MDS assessment. During an interview on 1/07/2026 at 4:20 PM the MDS RN stated that she had completed an MDS Assessment for a significant change for Resident #35 recently because she was admitted to hospice. She did not mark question J1400, regarding a prognosis of less than 6 months of life expectancy as 'yes,' because she did not see any documentation stating that prognosis. She was aware that for a resident to be admitted to hospice they had to have a terminal diagnosis and a life expectancy of six months or less.

Based on record review and interview, the facility failed to ensure Preadmission Screening and Resident Review (PASRR) was accurately completed for 3 of 8 residents, Residents #8, #11 and #26, reviewed for behavioral management.Findings include: Review of Resident #26's admission record documented the resident was admitted on [DATE] with diagnoses to include major depressive disorder (onset date: 8/8/2025).Review of Resident #26's PASSR dated 8/18/2025 did not show depressive disorder under mental illness or suspected mental illness under Section I: PASSR Screen Decision-Making.Review of Resident #26's quarterly Minimum Data Set assessment dated [DATE] documented Depression under Section I- Active Diagnoses.Review of Resident #26's [Name mental health provider] note dated 12/4/2025 read, History of Present Illness: Past psych history includes MDD [Major Depressive Disorder].Review of Resident #8's admission record documented the resident was admitted on [DATE] with diagnoses to include anxiety disorder (onset date: 1/29/2025) and depression (onset 1/29/2025).Review of Resident #8's PASSR dated 11/29/2025 did not show depressive disorder or anxiety disorder under mental illness or suspected mental illness under Section I: PASSR Screen Decision-Making.Review of Resident #8's quarterly Minimum Data Set assessment dated [DATE] documented Depression and Anxiety under Section I- Active Diagnoses.Review of Resident #8 [Name of mental health provider] note dated 12/18/2025 read, History of Present Illness: Past psych history includes insomnia not due to substance or known physiological condition, GAD [generalized anxiety disorder], dementia in other disease classified elsewhere, mild, with psychotic disturbance, MDD.Review of Resident #11's admission record documented the resident was admitted on [DATE] with diagnoses to include anxiety disorder (onset date 8/27/2025) and autistic disorder (onset date 8/27/2025).Review of Resident #11's PASSR dated 8/29/2025 did not show autistic disorder or anxiety disorder under mental illness or suspected mental illness under Section I: PASSR Screen Decision-Making.Review of Resident #11's quarterly Minimum Data Set assessment dated [DATE] documented Autistic and Anxiety under Section I- Active Diagnoses.Review of Resident #11 [Name of mental health provider] note dated 12/4/2025 read, History of Present Illness: Past psych history includes anxiety, insomnia, autistic.During an interview on 1/7/2026 at 10:16 AM the Social Service Director stated, I oversee PASARR in the facility. When residents come in if they have no PASARR, I will go ahead and reach out to Keppra and request one and make sure they have one on file. When they come in from the hospital with a PASARR already completed I review the form to make sure it has the facility's name. I was not comparing to see if all the diagnosis they have listed are marked on the form.Review of the policy and procedure titled Resident Assessment-Coordination with PASARR Program with a last review date of 1/22/2025 read, Policy: This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs.

Based on interview and record review, the facility failed to develop a care plan for 1 of 4 residents, Resident #11, reviewed for respiratory services and 1 of 8 residents, Resident #10, reviewed for behavioral management. Findings include: Review of Resident #11's physician order dated 9/24/2025 read, Oxygen 2L [liters] received via nasal cannula, may titrate to maintain SPO2 > 90% [peripheral capillary oxygen saturation greater than 90 percent] every shift for low oxygen saturation <90% [less than 90 percent]. Review of Resident #11 physician order dated 1/2/2026 read, Oxygen 2L received via nasal cannula, may titrate to maintain SPO2 > 90% every shift for low oxygen saturation < 90%. Review of Resident #11 care plan did not include oxygen as a focus. During an interview on 1/7/2026 at 11:53 AM the Minimum Data Set (MDS) Coordinator stated [Resident #11's name] care plan did not include oxygen as a focus or intervention, and it would need to be updated. Review of Resident #10's admission record documented the resident was admitted on [DATE] and diagnosis to include post-traumatic stress disorder (onset date 7/11/2023). Review of Resident #10's [Name of mental health provider] dated 12/18/2025 read, History of Present illness: Psychiatric history includes anxiety disorder, major depressive disorder, and post-traumatic stress disorder (PTSD). During an interview on 1/7/2026 at 10:08 AM the MDS Coordinator stated, I do not see a diagnosis of PTSD mention in the care plan. A focus will need to be added. Review of the policy and procedure titled Resident MDS Assessment and Care Planning Policy with a last review dated of 1/22/2025 read, CAA triggers are used as a basis for care planning. Additional areas care planned as determined by IDT [Intradisciplinary Team], additional assessment, diagnoses, facility policy or other concerns specific to resident.

Based on observation, interview, and record review the facility failed to administered medication appropriately, crushing extended-release medication for 1 of 5 medication observations [Resident #1].Findings include:During an observation on 1/8/2026 at 8:11 Staff E, Unit Manager/Licensed Practical Nurse (LPN) prepared Resident #1's medications for administration. One of the medications was Potassium Chloride Extended Release. Staff E crushed all of Resident #1's medications and administered the medications to Resident #1. Review of Resident #1 physician order dated 1/2/2026 read, Klor-Con 10 Oral Tablet Extended Release 10 MEQ [milliequivalent] (Potassium Chloride) give 1 tablet by mouth one time a day for hypokalemia.During an interview on 1/8/2026 at 9:45 AM the Director of Nursing stated, Extended-release medication should not be crushed. The nurse should call the provider and have the medication changed to a liquid or a type of medication can be crushed.During an interview on 1/8/2026 at 10:50 AM with Staff E, Unit Manager/License Practical Nurse stated, Extended-Release medication cannot be crushed. I have already contacted the provider and the family to notify them of what happened and get a change of medication.During an interview on 1/8/2026 at 1:32 PM the Advance Practical Registered Nurse #1 stated, Extended-Release medication should not be crushed. It was a onetime thing, [Resident #1's name] is okay. I have no messages from nursing staff [Resident #1's name] has had any health concerns.Review of the facility policy and procedure titled Administering Medications with a last review date 1/22/2025 read, Policy Statement: Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation. 7. If a dosage is believed to be inappropriate or excessive for a resident or is suspected if being associated with adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's attending physician or the facility's medical director to discuss the concerns. 9. The individual administering the medication checks the label to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.

Based on interview and record review the facility failed to ensure physician orders were followed for medication parameters for 1 of 6 residents, Resident #9, reviewed for medication management.Findings include: Review of Resident #9's physician order dated 2/2/2024 read, Losartan Potassium Tablet 25 mg [25 milligram] give 1 tablet by mouth two times a day for HTN [hypertension] Hold if BP [blood pressure] less than 90/50 or pulse less than 60 and notify MD [Medical Doctor].Review of Resident #9's Medication Administration Record (MAR) for the month of December 2025 for Losartan Potassium tablet 25 mg on 12/4/2025 at 2100 [9:00PM] pulse was 53 the medication was documented as administered, on 12/6/2025 at 0900 [9:00 AM] pulse was 58 the medication was documented as administered, 12/18/2025 at 0900 pulse was 59 the medication was documented as administered, 12/26/2025 at 900 pulse was 55 and at 2100 pulse was 56 and the medication was documented as administered, and on 12/27/2025 at 2100 pulse was 54 and the medication was documented as administered.Review of Resident #9's MAR for the month of [DATE] for Losartan Potassium tablet 25 mg on 1/1/2026 at 2100 pulse was 58 the medication was documented as administered. During an interview on 1/8/2026 at 9:45 AM the Director of Nursing stated, I expect nurses to follow the physician orders and call the provider if they have to clarify an order. The order was done by the old provider that over saw the facility.During an interview on 1/8/2026 at 11:07 AM Staff F, Licensed Practical Nurse stated, A check mark means medication is given.During an interview on 1/8/2026 at 1:32 PM the Advanced Practice Registered Nurse #1 stated, Nurses are to follow physician orders as given and contact us with any questions.Review of the facility policy and procedure titled Administering Medications with a last review date of 1/22/2025 read, Policy Statement: Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: 4. Medications are administered in accordance with prescriber orders, including any required time frame.

Based on observation, interview, and record review the facility failed to prevent the possible spread of infection for 1 of 4 residents, Resident #26 reviewed for respiratory service, 1 of 4 residents, Resident #11, reviewed for enhanced barrier precautions, 1 of 5 medication observations, Resident #13, and during dining.Findings include: During an observation on 1/5/2026 at 10:20 AM Resident #11's room door had an enhance barrier sign posted and personal protective equipment hanging outside of the room door. Resident #11 was sitting in his wheelchair. Staff B Certified Nursing Assistant (CNA) was inside of the room making the residents bed with only gloves on and no gown. Staff B, CNA collected the soiled linen on the floor in front of the resident's bathroom and placed the linens in a transparent plastic bag. Review of Resident #11's physician orders did not include orders for enhance barrier precautions. Review of Resident #11's physician order dated 1/2/2026 read, Tx [treatment] Sacrum: Cleanse with n/s [normal saline], pat dry. Apply anasept gel and collagen powder to wound bed, cover with ca [calcium] alginate and dry dressing daily and prn [as needed]. Review of Resident # 11 [Name of the wound care physician] wound evaluation and management summary dated 1/2/2026 read, focused wound exam stage 4 pressure wound sacrum full thickness. During an interview on 1/8/2026 at 9:45 AM the Director of Nursing (DON) stated, Staff is supposed to wear a gown and gloves when providing care. That includes when the staff is making the resident's bed and touching linen that had been on the bed. [Resident #11's name] is on enhance barrier precautions due to the pressure ulcer he has. Review of the facility policy and procedure titled Enhanced Barrier Precautions with a last review date of 1/22/2025 read, Policy Statement: Enhanced barrier precautions (EBPs) are utilized to prevent the spread of [NAME]-drug resistant organisms (MDROs) to residents. Policy Interpretation and Implementation. 3. Examples of high contact resident care activities requiring the use of gown and gloves for EBPs include: e. changing linens. During an observation on 1/5/2026 at 12:25 PM Staff B, CNA removed Resident #3's tray from the dietary cart and delivered the tray to the resident in the common area. Staff B, CNA assisted the resident in setting up the meal. Staff B returned to the dietary cart and without hand sanitizing removed Resident #41's tray and delivered the tray to the common dining room and assisted Resident #41 with meal set up. Staff B without sanitizing her hands returned to the dietary cart and removed Resident #67's meal tray and delivered the tray to the resident, Staff B offered to cut the meat for the resident which the resident accepted the help. Staff B returned to the meal cart and sanitized her hands using the sanitizing dispenser. During an interview on 1/7/2026 at 9:55 AM the DON stated, Staff should wash or sanitize their hands in between residents. During an interview on 1/8/2026 at 1:10 PM Staff B, CNA stated, You wear a gown and gloves when providing care to the resident. I normally wear a gown, I probably forgot. I always use hand sanitizer after each resident, I cannot remember. I probably forgot to use hand sanitizer. Review of the facility policy and procedure titled Handwashing/Hand Hygiene with a last review date of 1/22/2025 read, Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of healthcare associated infections. During an observation on 1/7/2026 at 8:30 AM Staff C, Registered Nurse (RN) entered Resident #26's room to take the residents vitals. Resident #26 was sitting in his wheelchair, there was a nasal cannula on the floor. Staff C, RN proceeded to pick up the nasal cannula and place it on Resident #26's nose. During an interview on 1/7/2026 at 8:44 AM with Staff C, RN, stated, I should have not placed the nasal cannula back on the resident after I found it on the floor. I should have cleaned it or gotten a new one. Review of Resident #26 physician order dated 1/2/2026 read, Continuously 02 @ 2L/M [oxygen at 2 liters per minute] for SOB [shortness of breath] every day and night shift for SOB. During an interview on 1/7/2026 at 9:56 AM the Director of Nursing stated, The staff should pick up the nasal cannula that was found on the floor and throw it away and go get a new one. Anything that falls on the floor goes in the trash. During an observation on 1/7/2026 at 8:59 AM Staff D, Licensed Practical Nurse (LPN) prepared Resident #13's medications and donned gloves, gown and a mask before entering the resident's room. Staff D checked for placement and residual before administering the medications into Resident #13's gastric tube and proceeded to also administer a bolus feeding. Staff D removed the syringe and did not rinse the syringe after using it and placed the syringe back in the plastic bag. The tip of the flush syringe had visible residue at the time of the medication administration and feeding. During an interview on 1/7/2026 at 9:17 AM Staff D, Licensed Practical Nurse (LPN) stated, I should have rinsed off the flush syringe after the administration and make sure all the junk is gone. During an interview on 1/7/2026 at 9:56 AM the Director of Nursing stated, The nurse should have rinsed the gastric tube flush syringe after use and then store it. Review of the policy and procedure titled Administering Medications through an Enteral Tube with a last review date of 1/22/2025 read, Purpose: The purpose of this procedure is to provide guidelines for the safe administration of medications through an enteral tube. General Guidelines: 7. Use a clean enteral syringe with an ENFit [safety connector for enteral feeding tubes] connector to administer medications through an enteral tube.

Based on observation and interview, the facility failed to post the current nurse staffing information to include the facility name, the current date, the total number and the actual hours worked by the licensed and unlicensed nursing staff directly responsible for resident care per shift, and the resident census.Findings include:During an observation on 1/05/2026 at 9:35 AM the plastic document holder for the posting of the daily staffing, which was hanging on the wall in the main hallway, across from the elevator was empty/contained no documents.During an interview on 1/5/2026 at 9:40 AM the Receptionist stated [name of the HR/Staffing Coordinator] was responsible for the staffing and she had no idea where it was supposed to be posted.During an interview on 1/5/2025 at 9:50 AM the Administrator stated the staffing was to be posted in the main hallway near the nurses' station on the 100 hall.During an observation on 1/5/2025 at 9:53 AM the staffing sheet posted in the hallway on the first floor (the 100 hall), across from the nurses' station, was dated Tuesday, August 12, 2025. (Photographic evidence obtained)During an interview on 1/05/2026 at 10:03 AM the Administrator stated the expectation was that the current staffing sheet was to be posted daily.During an interview on 1/05/2026 at 10:04 AM the DON stated the expectation is that the staffing is supposed to be posted by 9:00 AM daily. It was to be posted near the lobby, across from the elevator.During an interview on 1/08/2026 at 10:25 AM the HR [Human Resources]/Staffing Coordinator stated that she posts the staffing sheet in the morning following the morning meeting, which was usually after 9:30 [AM].

Based on observation, interview, and policy and procedure review, the facility failed to ensure food is safely stored, covered, and/or labeled in the areas of the nutrition room and food trays delivered to the floors. Findings include: During an observation on 7/29/24 at 10:00 AM of the nutrition room on the first floor, inside the refrigerator was an open package of Bologna not dated or sealed. (Photographic evidence obtained). During an interview on 7/29/24 at 10:00 AM the Dietary Manager stated, Its dietary's responsibility to check the nourishment rooms in the morning and clean them out as needed. During an interview on 7/29/24 at 10:00 AM the Dietary Manager confirmed the bologna was not sealed in the package or dated. During an observation on 7/30/24 at 7:51 AM of the breakfast meal delivered to the first floor from main kitchen, showed half cut bananas not covered on individual resident trays. (Photographic evidence obtained). During an interview on 7/30/24 at 7:52 AM the Administrator, who walked up at the time the trays were delivered, said, I do not know why the cut bananas were not covered. During an interview on 7/30/24 at 8:10 AM the Dietary Manager stated, I am not sure why the bananas that are cut in halves are not wrapped. A request was made for the policy and procedure related to food tray delivery. During an interview on 8/1/24 at 10:14 AM the Dietary Manager stated, There is no food tray delivery policy and procedure. Review of the policy and procedure titled, Foods Brought by Family/Visitors, reviewed on January 11, 2024, read, Policy Statement: Food brought to the facility by visitors and family is permitted. Facility staff will strive to balance resident choice and a homelike environment with the nutritional and safety needs of residents. Policy Interpretation and Implementation: 1. Family members and visitors are asked to inform nursing staff when foods are brought for a resident. 5. Food brought by family/visitors that is left with the resident to consume later is labeled and stored in a manner that is clearly distinguishable from facility-prepared food. a. Nonperishable foods are stored in re-sealable containers with tight fitting lids. Intact fresh fruit may be stored without a lid. b. Perishable foods are stored in re-sealable containers with tightly fitting lids in a refrigerator. Containers are labeled with the resident's name, the item and the date. 6. The nursing staff will discard perishable foods within 3-5 days. 7. The nursing and /or food service staff will discard any foods prepared for the resident that shows obvious signs of potential foodborne danger (for example, mold growth, foul odor, past due package expiration dates).

Based on observation, interview, and record review, the facility failed to ensure care and services were provided for central venous access catheters, in accordance with professional standards of practice, by failing to provide necessary central venous dressing changes, for 1 of 2 residents, Resident #71, reviewed with a central venous catheter. (Photographic evidence obtained) Findings include: During an observation on 7/29/2024 at 10:00 AM Resident #71 was sitting upright in bed with a right upper arm single lumen peripherally inserted central catheter (PICC) line. The PICC line was covered by a transparent dressing which was lifting up on three sides of the dressing and had a 2 x 2 gauze under the transparent dressing. The PICC line had a date of 7/24/24 and a time of 11:00 PM documented on the dressing. During an observation on 7/29/2024 at 12:30 PM, Resident #71 had a transparent dressing covering the PICC line IV (intravenous) site on her right upper arm. There was a 2 x 2 gauze under the transparent dressing and three sides of the dressing were lifting up. The dressing was dated 7/24/24, with a time of 11:00 PM documented. Review of Resident #71's Admission Record documented she was admitted to the facility on [DATE] with the following diagnoses: other acute osteomyelitis, right ankle and foot; diabetes mellitus due to underlying condition with diabetic neuropathy, type 2 diabetes mellitus with foot ulcer. Included in the admission record was documentation of an IV site/PICC line, no location of the IV site/PICC line insertion site was documented. Review of Resident #71's physician orders dated 6/21/24, read, Flush PICC line [in] right arm before and after administration of IV with 10CC (cubic centimeters) saline two times a day for osteomyelitis [in the] right foot Review of Resident #71's physician orders dated 6/24/24 read, Change IV/PICC dressing and caps weekly on 7p-7a every night shifts every Wed [Wednesday] for Prophylactic [guarding from or preventing the spread or occurrence of disease or infection]. Review of Resident #71's physician orders dated 7/25/24 read, Meropenem Intravenous Solution Reconstituted 1 GM (gram) (Meropenem). Use 1 gram intravenously two times a day for osteomyelitis [an infection in the bone] for 14 Days. During an observation on 7/30/2024 at 9:30 AM, Resident #71 was observed sitting up in bed, with her IV antibiotics, Meropenem (used to treat infections caused by bacteria), Intravenous Solution, 1 gram, infusing into the PICC line IV site in her right upper arm. The PICC line IV site was observed to be covered with a transparent dressing, with the edges lifting on three sides from her skin. There was a 2 x 2 gauze pad observed under the transparent dressing. The dressing had a date of 7/24/24 and a time of 11:00 PM documented. During an interview on 7/31/2024 at 9:55 AM, the Assistant Director of Nursing (ADON), stated, PICC line dressing changes are once a week and prn (Pro Re Nata/as needed). There should be something circular [antimicrobial sponge] at the [insertion] site. There should also be something other than Tegaderm [transparent occlusive dressing], there should be gauze or a split sponge under the Tegaderm. The only reason to change the dressing more often than once a week would be if the dressing was stained, like with blood. That's why we have the prn order. There is also an order to check the site for signs and symptoms of infection every shift. The gauze under the Tegaderm just gives something to grab when pulling off the Tegaderm. During an interview on 7/31/2024 at 10:15 AM, Staff A, Licensed Practical Nurse (LPN), stated, We do [PICC line] dressing changes every week. The kit has an occlusive dressing. The gauze in the kit is to dry the site. I only apply an occlusive (transparent) dressing. Gauze should not be under the occlusive dressing at all. If there is gauze, it should only be there, or on any wound, for 24 hours. During an interview on 7/31/2024 at 10:40 AM the Director of Nursing (DON), stated, We change the dressings on PICC lines once a week and prn, if it is saturated or loose. The dressing would have the round thing (antimicrobial disc) and the clear dressing (transparent occlusive dressing) on top. There should be no gauze. The kits have gauze, and sometimes when the line is first put in, it can be bloody and need the gauze. If there is gauze, the dressing needs to be changed within 24 hours. During an interview on 7/31/2024 at 12:15 PM, Staff A, LPN, stated, I gave her [Resident #71] morning antibiotics this week [7/29/2024, 7/30/2024, 7/31/2024]. I didn't change it [PICC line dressing] earlier this week, because I didn't think it needed to be changed. During an interview on 8/1/2024 at 11:15 AM, Staff F, LPN, stated, I took care of [Resident #71's name] last weekend [7/27/2024, 7/28/2024]. I remember she had a PICC line and was getting IV antibiotics. I gave them [the IV antibiotics] on my shift. There is usually gauze under the occlusive dressing, I had no idea it wasn't supposed to be there. During an interview on 8/1/2024 at 12:00 PM, Staff G, LPN, stated, I would have been the one to give her [Resident #71] antibiotics. I'm sure I gave the antibiotics both days [7/27/2024 and 7/28/2024]. The dressing was intact, but I did not notice there was gauze under the occlusive dressing. I didn't know the policy says there shouldn't be any gauze under the transparent occlusive dressing. I know gauze dressings are supposed to be changed every two days, but I didn't notice that there was gauze. During an interview on 8/1/2024 at 12:45 PM, the DON, stated The nurses are supposed to assess PICC sites every shift and change the dressings once a week or as needed, if the dressing is loose or soiled. There should not be any gauze. I expect the nurses to assess the insertion site and quality of the dressing and change it according to our policy. Review of the policy and procedures titled, Central Venous Catheter Care and Dressing Changes, last revised 3/2022, review date of 1/11/2024, read, Purpose - The purpose of this procedure is to prevent complications associated with therapy, including catheter-related infections that are associated with contaminated, loosened, soiled, or wet dressings. General Guidelines - 1. Perform site care and dressing change at established intervals or immediately if the integrity of the dressing is compromised (e.g., damp, loosened or visibly soiled). 2. Maintain sterile dressing (transparent semi-permeable membrane [TSM] dressing or sterile gauze) for all central vascular access devices. The type of dressing is based on the condition of the resident and his or her preference. 3. Change the dressing if it becomes damp, loosened or visibly soiled and: a. at least every 7 days for TSM dressing; b. at least every 2 days for sterile gauze dressing (including gauze under a TSM unless the site is not obscured); or c. immediately if the dressing or site appear compromised.

Based on observation, interview, and record review, the facility staff failed to follow physician orders and ensure that oxygen was administered consistent with professional standards of practice for 3 out of 4 residents reviewed for respiratory care (Resident #27, #30 and #46) Findings include: 1. Review of Resident #27's admission record documented diagnoses that included unspecified systolic congestive heart failure, anemia unspecified, and atherosclerotic heart disease of native coronary artery without angina pectoris. Review of Resident #27's physician orders dated 9/7/2022 read, Deliver oxygen at 2L [liters]/min [minute] via nasal cannula. During an observation on 7/29/2024 at 12:34 PM Resident #27 was resting in bed, oxygen was being administered at 4 liters per minute via nasal cannula that was attached to an oxygen concentrator. The oxygen concentrator was at the head of the bed on the right side of the bed and outside of the resident's reach. During an observation on 7/30/2024 at 7:44 AM Resident #27 was resting in bed, oxygen was being administered at 4 liters per minute via nasal cannula that was attached to an oxygen concentrator. The oxygen concentrator was at the head of the bed on the right side of the bed and outside of the resident's reach. During an observation on 07/30/24 at 02:45 PM of Resident #27, conducted with Staff A, Licensed Practical Nurse (LPN), it showed oxygen was being administered at 4 liters per minute via nasal cannula that was attached to an oxygen concentrator. The oxygen concentrator was at the head of the bed on the right side of the bed and outside of the resident's reach. Staff A, LPN, during the observation, changed the oxygen administration to 3 liters per minute. During an interview on 7/30/2024 at 2:47 PM Staff A, LPN stated, That is not correct [the oxygen]. I'm not sure how it got on that high. Her orders [Resident #27] are for 2 liters and I will change that. I should check oxygen when I am administering medications. I am not aware of any reason we would have needed to change the rate of the oxygen. Review of the nursing progress notes for the period of 7/14/2024 through 07/30/2024 did not document the need to increase the oxygen administration dosage, changes in the resident's respiratory status, or notification to the physician of a change in the resident's oxygen administration rate. During an interview on 8/1/2024 at 7:30 AM the Director of Nursing (DON) stated, I expect staff to assess residents on oxygen at a minimum daily and make sure that we are following the orders for correct oxygen administration. 2. During an observation on 7/29/2024 at 12:39 PM Resident #30 was in bed with oxygen being administered via nasal cannula. The oxygen concentrator was set at 3 liters per minute. The oxygen concentrator was at the left side and at the head of the bed outside of the reach of the resident. During an observation on 7/30/2024 at 7:48 AM Resident #30 was in bed with oxygen being administered via nasal cannula. The oxygen concentrator was set at 3 liters per minute. The oxygen concentrator was at the left side and at the head of the bed outside the reach of the resident. Review of Resident #30's admission record which documented diagnoses that included heart failure, unspecified, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, type 2 diabetes mellitus without complications, aphasia following cerebral infarction, dysphasia following cerebral infarction, and essential primary hypertension. Review of Resident #30's physician orders dated 12/20/2023 read, Continuous O2 [oxygen] at 2L [liters] via NC [nasal cannula]. Review of Resident #30's progress notes for the period of 7/19/2024 through 7/30/2024 did not provide for documentation of changes in condition, a change in respiratory status, shortness of breath, or the physician having been notified of a change in the administration of oxygen. During an observation on 7/30/2024 at 2:48 PM Staff A, LPN verified the oxygen was running at 3 liters per minute. During an interview on 7/30/2024 at 2:48 PM Staff A, LPN stated, Her orders [Resident #30] are for 2 liters of oxygen. I should check daily for what oxygen is running at. During an interview on 7/31/2024 at 9:42 AM the DON stated, The nurses should be checking oxygen every day, when they go from portable tanks to concentrators, and when they have any changes in their respiratory functioning. 3. During an observation on 7/29/2024 at 10:29 AM Resident #46 was in bed with oxygen being administered via nasal cannula. The oxygen concentrator was set at 5 liters per minute. The oxygen concentrator was at the left side and at the head of the bed outside the reach of the resident. During an observation on 7/30/2024 at 7:43 AM Resident #46 was in bed with oxygen being administered via nasal cannula. The oxygen concentrator was set at 6 liters per minute. The oxygen concentrator was at the left side and at the head of the bed outside the reach of the resident. During an interview on 7/30/2024 at 7:44 AM Resident #46 stated, I do not change the machine, sometimes I take my oxygen off at my nose, but I can't reach the machine to change it. Review of Resident #46's admission record documented diagnoses that included acute and chronic respiratory failure, unspecified whether with hypoxia [low oxygen] or hypercapnia [high carbon dioxide], type 2 diabetes mellitus without complications, heart failure, unspecified, and essential (primary) hypertension. Review of Resident #46's physician orders dated 12/20/2023 reads, O2 at 3 L/m via nasal cannula. During an observation on 7/30/2024 at 2:44 PM Staff A, LPN verified that the oxygen was running at 6 liters per minute, During an interview on 7/30/2024 at 2:48 PM Staff A, LPN stated, It [the oxygen] is on 6 liters and should be on 4 liters. I am responsible for making sure that the oxygen is running at the right rate. We should be following physician orders for oxygen. During an interview on 8/01/2024 at 9:09 AM the DON stated, I expect staff to follow physician orders for oxygen use. They should check at least daily. Review of the policy and procedure titled, Oxygen Administration last approval date of 01/11/2024 read, Purpose: The purpose of the procedure is to provide guidelines for safe oxygen administration. Preparation: 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Steps in the procedure: 13. Observe the resident upon setup and periodically thereafter to be sure oxygen is being tolerated.

Based on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the resident's diet for 2 (Resident #53 and Resident #31) of 3 residents sampled for nutrition and 1 (Resident #1) of 1 residents reviewed for restraints. Findings include: 1. During an observation on 3/20/2023 at 12:35 PM, Resident #53 was sitting in her room eating independently. The resident's meal ticket read, Mechanically soft, ground meat, mashed potatoes, green bean salad, juice, and crumb cake. During an observation on 3/22/2023 at 12:40 PM, Resident #53 was sitting in her room eating independently. The resident's meal ticket read, Mechanically soft, finely chopped chicken, noodles, green beans, apple sauce, and juice. Review of the admission record documented that Resident #53 was admitted to the facility on [DATE] with diagnoses including but not limited to hemiplegia and hemiparesis following cerebral infarction affecting right non-dominant side, dysphagia following nontraumatic intracerebral hemorrhage, aphasia following cerebral infraction, and gastro-esophageal reflux disease with esophagitis without bleeding. Review of the physician order for Resident #53 dated 11/20/2022 read, Regular diet mechanical soft texture, thin/regular consistency, Diet - Mechanical soft, thin liquids. Fortified pudding with lunch and dinner for weight loss Review of Resident #53's MDS Quarterly assessment dated [DATE] read, Section K - Swallowing/Nutritional Status, K0510 Nutrition approaches: C. Mechanically altered diet - require change in texture of food or liquids (e.g., pureed food, thickened liquids), 2. While a resident: 0. Not checked (No) During an interview on 3/22/2023 at 1:19 PM, the MDS Coordinator stated, [Resident #53's name] is on a mechanical soft diet. I probably saw the regular and did not go any further. 2. During an observation on 3/20/2023 at 12:39 PM, Resident #31 was eating independently in his room. The resident's meal ticket read, Mechanical soft, ground meat, mashed potatoes, green beans, desert and juice. During an observation on 3/22/2023 at 12:43 PM, Resident #31 was eating independently in his room. The resident's meal ticket read, Mechanical soft, finely cut chicken, noodles, apple sauce, green beans and juice. Review of the admission record documented Resident #31 was admitted to the facility on [DATE] with diagnoses including but not limited to dysphagia, dementia in other disease classified elsewhere, moderate, without behavioral disturbance, and anemia. Review of the physician order for Resident #31 dated 2/22/2023 read, Regular diet mechanical soft texture, thin/regular consistency. Review of Resident #31 MDS Medicare 5-day assessment dated [DATE] read, Section K - Swallowing/Nutritional Status, K0510 Nutrition approaches: C. Mechanically altered diet - require change in texture of food or liquids (e.g., pureed food, thickened liquids), 2. While a resident: 0. Not checked (No) During an interview on 3/22/2023 at 1:20 PM, the MDS Coordinator stated, [Resident #31's name] is on a mechanical soft diet, [the MDS] should be changed. 3. During an observation on 3/20/2023 at 9:33 AM, Resident #1 was lying in bed, with no bed rails noted. During an observation on 3/21/2023 at 10:00 AM, Resident #1 was lying in bed, with no bed rails noted. Review of the admission record documented that Resident #1 was admitted to the facility on [DATE] with diagnoses including but not limited to paralytic ileus, unspecified convulsions, bipolar disorder, unspecified psychosis not due to substance or known physiological condition, anxiety disorder, schizophrenia, other specified depressive episodes, and other specified mental disorders due to known physiological. Review of the physician orders for Resident #1 on 3/22/2023 revealed no orders for bed rails. Review of Resident #1's MDS Quarterly assessment dated [DATE] read, Section P - Restraints and Alarms, P0100 Physical Restraints, Used in Bed: A. Bed Rail: 2. Used daily. During an interview on 3/22/2023 at 9:01 AM, Staff B, License Practical Nurse (LPN) stated, [Resident #1's Name] does not use any restraints. She does not have bed rails. During an interview on 3/22/2023 at 1:15 PM, the MDS Coordinator stated, [Resident #1's Name] used half rails at times. That [the MDS] is not supposed to say bed rails as restraints. Review of the policy titled Resident MDS Assessment and Care Planning Policy last reviewed on 12/15/2022 read, Purpose: To ensure facility compliance with regulations pertaining to Resident Assessment. To encourage resident and family input in assessment process. To provide interdisciplinary observation and assessment to ensure the most accurate assessment of resident functional capacity. To develop an individual Care Plan for the resident.

Based on interview and record review, the facility failed to ensure a resident who was newly admitted with a serious mental illness received a referral to the appropriate state-designated authority for Level II PASARR (Preadmission Screening and Resident Review) evaluation and determination for 1 (Resident #53) of 6 residents reviewed for PASARR. Findings include: Review of the admission record documented Resident #53 was admitted to the facility on [DATE] with diagnoses including but not limited to schizophrenia. Review of PASARR for Resident #53 dated 5/5/2022 read, Section I: PASRR Screen Decision Making, A. MI [Mental Illness] or suspected MI (check all that apply): Schizophrenia, Section IV: PASRR Screen Completion: Individual may not be admitted to a Nursing Facility. Use this form and required documentation to request a Level II PASRR evaluation because there is a diagnosis of or suspicion of (Check on of the following): Serious Mental Illness. Review of KEPRO (Keystone Peer Review Organization) PASRR Notice of the Need for Further Evaluation dated 5/5/2022 read, Results from your screening. There are two screening levels. You have done Level I. The results are below. Signs of a serious mental illness were found. Level II screening is needed. Results of screening will be sent to you when done. Your Level I screener will request this Level II screening. We will notify you with the result. Review of Resident #53's Minimum Data Set (MDS) Quarterly assessment dated [DATE] read, Section I Active Diagnoses, Psychiatric/ Mood Disorder: I6000. Schizophrenia. During an interview on 3/21/2023 at 9:32 AM, the Social Services Director stated, [Resident #53's Name] does not have a PASARR Level II Screening. I went into KEPRO database and was not able to find one. I do not know why they did not do it. During an interview on 3/23/2023 at 10:55 AM, the Administrator stated, My expectations is if the resident is not a provisional stay and will be long term the Level II screening should have been completed and that is part of the admission process. Review of the policy titled Resident Assessment- Coordination with PASARR Program, last reviewed 12/15/2022 reads, Policy Explanation and Compliance Guidelines: 1b. PASARR Level II - a comprehensive evaluation by the appropriate state-designated authority (cannot be completed by the facility) that determines whether the individual has MD (mental disorder), ID (intellectual disability) or related condition, determines the appropriate setting for individual, and recommends any specialized services and /or rehabilitative services the individual needs. 2. The facility will only admit individuals with a mental disorder or intellectual disability who the State mental health or intellectual disability authority has determined as appropriate for admission.

Based on observation, interview, and record review, the facility failed to ensure care and services were provided for central venous access devices in accordance with professional standards of practice for 1 (Resident #313) of 1 residents reviewed with a central venous access devices. Findings include: During an observation on 3/20/2023 at 9:50 AM, Resident #313 was lying in bed with a single lumen midline on right upper arm dated 3/10/2023. During an interview on 3/20/2023 at 9:51 AM, Resident #313 stated, The midline was inserted in the hospital before leaving. The staff here have not changed my dressing. I have not refused any care related to my midline. Review of the admission record documented Resident #313 was admitted to the facility on [DATE] with the diagnoses including but not limited to pressure ulcer of left hip, stage 3, morbid obesity due to excess calories, vitamin D deficiency, and dietary calcium deficiency. Review of the Medical Certification For Medicaid Long-Term Care Services and Patient Transfer Form for Resident #313 dated 3/10/2023 read, V. Treatment Devices: IV/PICC (intravenous/peripherally insert central catheter) / Portacath Access-Date inserted: 3/10/2023 type: midline. Review of the physician orders for Resident #313 dated 3/19/2023 read, Change IV dressing every 7 days and as needed. Every day shift every Sat [Saturday] and every 24 hours as needed for protocol. During an interview on 3/22/2023 at 2:40 PM, the Director of Nursing stated, [Resident #313's Name] dressing was dated 3/10/2023, IV dressing should be changed every 7 days or as needed. Orders [physician] are in the system and should be followed. Review of policy titled IV Peripheral Venous Access last reviewed 12/15/2022 read, 4. IV sites shall be rotated every 7 days and as needed per facility policy. Physician's order and documentation is required.

Based on observation, interview, and record review, the facility failed to ensure respiratory care services were provided consistent with professional standards of practice for oxygen administration for 2 of 4 sampled residents (Residents #32 and #59). Findings include: 1. During an observation on 3/20/2023 at 12:58 PM, Resident #32 was sitting in an electric wheelchair with oxygen running at 3 liters per minute via a nasal cannula. During an observation on 3/21/2023 at 8:34 AM, Resident #32 had oxygen running at 3 liters per minute via a nasal cannula. During an interview on 3/21/2023 at 8:34 AM, Resident #32 stated, It is supposed to be set at 2 liters. I do not change my oxygen setting. During an observation on 3/22/2023 at 8:19 AM, Resident #32 had oxygen running at 3 liters per minute via a nasal cannula. Review of the physician order for Resident #32 dated 6/27/22 read, Deliver Oxygen @ [at] 2 liters/minute via Cannula PRN [as needed]. During an interview on 3/22/2023 at 1:48 PM, Staff A, Licensed Practical Nurse (LPN), stated, [Resident #32's name] should be on 2 liters of oxygen and the setting they are on now reads 3.5 liters per minute. That is not correct. 2. During an observation on 3/20/2023 at 1:19 PM, Resident #59 was lying in bed, wearing a nasal cannula with oxygen running at 2 liters per minute. During an observation on 3/21/2023 at 8:18 AM, Resident #59 was lying in bed, wearing a nasal cannula with oxygen running at 2 liters per minute. During an observation on 3/22/2023 at 8:24 AM, Resident #59 had oxygen running at 2 liters per minute. During an interview on 3/22/2023 at 8:24 AM, Resident #59 stated, I don't mess with that thing [oxygen concentrator]. Review of the physician order for Resident #59 dated 10/26/2022 read; O2 [Oxygen] at 3 L/M [liters per minutes] via Nasal Cannula. During an interview on 3/22/2023 at 2:05 PM, Staff A, LPN stated, [Resident #32's name] should be at 3 liters of oxygen. The Oxygen concentrator is set on 2 liters per minute. Review of the facility policy titled Oxygen Administration, last reviewed on 12/15/2022 read, Section 1. Oxygen is administered under orders of a physician.

Based on observation, interview, and record review, the facility failed to serve food in accordance with professional standards for food service safety. Findings: An observation of the nourishment room on the second floor on 10/4/2021 at 1:45 PM with the Dietary Manager showed the ice machine had a black substance on the bottom edge of the baffle (ice guard) (Photographic evidence obtained). During an interview on 10/4/2021 at 1:46 PM, the Dietary Manager stated, The ice machine is to be cleaned twice a month. This one needs to be cleaned. An observation of the nourishment room on the first floor on 10/4/2021 at 1:53 PM with the Dietary Manager showed the ice machine had a black substance on the baffle (ice guard) and the microwave had used paper towels on the bottom surface and food particles on the top and side surfaces of the microwave (Photographic evidence obtained). During an interview on 10/4/2021 at 1:54 PM, the Dietary Manager confirmed the microwave should have been cleaned after use and stated, The ice machine is to be cleaned twice a month also. This one needs to be cleaned. Review of the facility policy titled, Sanitation of Ice Machine reviewed on 9/21/2021 read, Policy: It is the policy of this facility that the ice machine shall be sanitized twice monthly by dietary . Sanitation: 5. All equipment is cleaned as needed.

Based on record review and interview, the facility failed to ensure residents that received Medicaid benefits were notified when the amount in the resident's account reached $200 less than the SSI (Supplemental Security Income) resource limit for 2 of 3 residents, Residents #24 and #3, in a total sample of 28 residents. Findings: Review of Resident #24's trust account activity beginning on 3/8/2021 revealed a balance of $2,765.89. There was no documentation showing the resident was notified his account was over the eligible limit. The account balance on 4/5/2021 revealed a balance of $1,981.99. There was no documentation showing the resident was notified his account was over the eligible limit. The account balance on 6/9/2021 was $1,805.14. There was no documentation showing the resident was notified his account was over the eligible limit. The account balance on 7/2/2021 was $1,935.21. There was no documentation showing the resident was notified his account was over the eligible limit. The account balance on 8/3/2021 was $2,065.29. There was no documentation showing the resident was notified his account was over the eligible limit. The account balance on 9/3/2021 was $2,117.14. There was no documentation showing the resident was notified his account was over the eligible limit. There was no documentation of the resident being notified of the account balance prior to the account reaching the eligibility limit of $200.00. There was no documentation in the record of the resident's representative being notified of the account balances. Review of Resident #3's trust account activity beginning on 9/10/2021 revealed a balance of $1,845.23. There was no documentation of the resident or the resident's representative being notified the account was over the $200.00 eligibility limit. During an interview on 10/7/2021 at 7:45 AM, Staff I, Business Office Manager, stated, I have looked through his [Resident #24's] file and there are no notices that the resident was notified that he was over or within the $200.00 dollars of his allowable limit. I did not send a notification to [Resident #3's name] about being within the $200.00 limit and I should have. Review of the facility policy titled, Resident Trust Fund Policy regarding Notification of Responsible Party of near Medicaid Eligibility Limits with an approval date of 9/1/2021 read, The Business Office Manager, or designee, will provide a letter to the resident, (or resident's responsible party), notifying them when the residents trust account balance is nearing $200 of the allowable the [Sic.] Medicaid limit, or exceeding the allowable limit, for funds in the account. Review of the facility policy titled, Resident Trust Fund Policy & Reconciliation Requirements read, General Guidelines: . 11. A resident and/or responsible party who receive Medicaid benefits will be notified when their trust account balance reaches $1,800.00.

Based on observation, record review, and interview, the facility failed to provide a safe, clean, comfortable and homelike environment for 13 of 48 sampled residents, Residents #15, #3, #12, #14, #16, #54, #52, #37, #40, #20, #6, #25, and #47, for 1 of 2 common living areas, and 2 of 2 medication storage rooms. Findings: 1. During the initial tour on 10/4/2021 at approximately 9:30 AM with Staff A, Certified Nursing Assistant (CNA), observation of Resident #15's room showed the mattress was about 6 inches short of the bed frame, which left an open area revealing the steel frame with the springs. The exposed area measured approximately 6 inches by 36 inches (Photographic evidence obtained). During an interview on 10/4/2021 at 9:35 AM, Resident #15 stated, They removed a wedge that was in that area and never brought the wedge back. During a tour of the facility on 10/6/2021 beginning at 8:30 AM with the Director of Plant Operations, an observation showed three dirty ceiling light diffusers in the lobby at the front door, a chair with the fabric completely worn through in the large common living television room area on the first floor. There were rusted door jambs observed pulling away from the walls in the rooms for Residents #3, #12, #14, #16, and #54. Resident #52's bathroom showed fecal matter in clumps on the floor. In Resident #37's room, there was a dirty, brown stained privacy curtain. Resident #40's room had an uneven patched area with a hole from the middle of the wall to the baseboard, behind the door. Resident #20's wall behind the door had a panel for utilities, which was secured to the wall with black tape. In the hall on the second floor outside of Resident #53's room, there was a dirty ceiling light diffuser with a crack about 10 inches long. Resident #6's room had a dirty privacy curtain and the overbed table had a 3 inch by 4 inch piece of the laminate finish missing. The missing laminate caused an exposure of unfinished wood. The sinks in Residents #25 and #47's rooms showed the water drained very slowly out of the sinks. During an interview on 10/6/2021 at 9:35 AM, the Director of Plant Operations verified the mattress in Resident #15's room did not fit the bed properly. She verified the door jambs, baseboards and walls needed repair. She stated the overbed table needed to be replaced. She verified the slow drains in the sinks in Resident #25 and #47's rooms, the fecal matter on the floor in Resident #52's room, and the dirty privacy curtains in Residents #37 and #6's rooms. Review of the Maintenance Logs since 9/5/2021 revealed one white paper in a binder with different handwritten phrases for complaints. The forms were no longer in use. There were no entries for the dirty, worn television chair, taped wall panel, cracked and dirty light diffusers, the overbed table missing a section of laminate, holes in the walls, dirty floors and privacy curtains. Review of the facility policy and procedure titled, Cleaning and Disinfecting of Environmental Surfaces read, Policy Statement: Environmental surfaces will be cleaned and disinfected according to current CDC recommendations for disinfection of healthcare facilities and the OSHA [Occupational Safety and Health Administration] Bloodborne Pathogens standard. During an interview on 10/6/2021 at 12:00 PM, the Administrator stated, The staff should be noting issues in the log at the nurse's station. This is part of their Guardian Angel Program. 2. An observation of the medication room on the first floor on 10/4/2021 at 9:30 AM with Staff H, Licensed Practical Nurse (LPN), showed the floors had a brown film with multiple spots of a dark brown substance. There was trash overflowing from the trash can onto the floor. The floor had a layer of debris behind the door of the medication room. The sink had four silver color pouches on the left side. There was a tan/yellow brown substance on the bottom of the sink and around the drain. The other side had several partial stickers stuck on the bottom of the sink, with a brown dark tan substance on the sink bottom and around the drain. There was a dark brown substance around the sink handles, and the counters had multiple stains that were brown dried circular rings. During an interview on 10/4/2021 at 9:35 AM, Staff H, Registered Nurse (RN), stated, The housekeepers need to be in here with someone. I'm not sure how frequently it is cleaned. There are old stickers on the bottom of the sink. It does have some stuff on the bottom of the sink, and the counters have old coffee cup marks on them. An observation of the medication room on the second floor on 10/4/2021 at 9:45 AM showed the left side sink basin had a tan/brown substance on the bottom and around the drain. The right side of the sink basin contained five silver pouches. The bottom of the sink had a sticky brown substance, and the faucet area had a brown substance around the handles. The floor had multiple dark brown stains that were able to come off with water and dust that could be removed. There was a storage closet with the handle covered with tape that had brown stains on it. During an interview on 10/4/2021 at 9:55 AM, Staff H, RN, stated, The sink needs to be cleaned. The tape on the handle is dirty, and I do not know why it is on there. The floor really needs to be cleaned. During an interview on 10/4/2021 at 12:35 PM, the Director of Nursing (DON) stated, The stains appear to be from coffee cups. The floor really needs to be cleaned and there is dust and other things on the floor. It is very dirty. Review of the facility policy and procedure titled, Storage of Medications revised in April 2007, with an approval date 9/1/2021, read, Policy Interpretation and Implementation: . 2. The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe and sanitary manner. 3. An observation of Resident #47's room on 10/4/2021 at 11:57 AM showed his bedroom window screen was not securely attached to the window frame. The screen was not fully attached to the bottom of the screen frame and there was a gap between the screen frame and window frame. Resident #47's window was observed to be cranked open (Photographic evidence obtained). During an interview on 10/4/2021 at 11:58 AM, Resident #47 stated, My window screen is not tight against my window and I like my windows cranked open. Bugs can crawl or fly into my window. An observation of Resident #47's room on 10/5/2021 at 8:39 AM showed the window screen was not securely attached to the window frame and the screen was not fully attached to the bottom of the screen frame. During an interview on 10/5/2021 at 8:40 AM, Resident #47 stated, Bugs could come in the window with the screen open like that.

Based on observation, record review, and interview, the facility failed to ensure each resident received adequate assistance to prevent accidents while transfer for 1 of 3 sampled residents, Resident #14, in a total sample of 28 residents. Findings: During an interview on 10/4/2021 at approximately 11:00 AM, Resident #14 stated, My transfers scare me. I am worried because they move me from side to side and the sling is uncomfortable, sometimes it hurts. The battery goes dead sometimes when I am in the process of the transfer. During an observation of Resident #14 on 10/4/2021 at 1:15 PM, Staff A, Certified Nursing Assistant (CNA), and Staff B, CNA, assisted Resident #14 to transfer from the wheelchair to the bed with the use of a Hoyer mechanical lift. Staff A and Staff B did not lock the wheelchair brakes prior to beginning the lift or at any time during the lift. Resident #14 asked, Are you sure the battery is charged? Staff A stated, Yes, it is charged this time. Remember it moves slower when it is not charged. The resident stated, Finally. During an interview on 10/4/2021 at 1:45 PM, Staff A, CNA, and Staff B, CNA, verified they did not use the locks. They stated they completed the transfer the same way they usually do. During an interview on 10/6/2021 at 9:00 AM, the Occupational Therapist verified the wheelchair locks on Resident #14's wheelchair should be locked prior to any transfers. She stated the locks can be disengaged as needed and then relocked during the transfer. Review of Resident #14's care plan dated 1/26/2021 read, Interventions: . Up in wc [wheelchair] for distance and make sure it is locked before all transfers, . Assist of 1 with mobility, assist of 2 with Hoyer lift for transfers at this time, . bed in lowest position and make sure it is locked. Review of the facility policy and procedure titled, How to Transfer Resident from a Wheelchair to a Bed, read, Instructions: . Step 2. Lock the wheels on the wheelchair and the bed (optional). Make sure the wheelchair is positioned so it is parallel to the bed, facing the foot end of the bed or at a 45-degree angle to the bed. It also should be near the middle of the bed. During an interview on 10/5/2021 at approximately 8:15 AM, the Assistant Director of Nursing verified they expect the staff to use the wheelchair locks during all the transfers. She verified the word optional in the policy was not for the wheelchair locks.

Based on interview and record review, the facility failed to follow proper procedure for repositioning a resident causing a major injury for 1 of 8 residents reviewed for accidents, Resident #24, in a total sample of 43 residents. Findings Include: A review of the facility reported incident sent to the Agency for Health Care Administration revealed a bruise was found on Resident #24's left shoulder during a transfer to the toilet. Resident was transported to the emergency room for imaging which revealed an acute left clavicle fracture, moderate Arthritis, and [MEDICAL CONDITION]. Further investigation by the facility revealed two staff members, Certified Nursing Assistants (CNA) Staff K and Staff L, repositioned Resident #24 in her wheelchair by putting their arms under the resident armpits and pulled her up. A review of the x-ray completed on 12/21/19 for Resident #24 revealed left clavicle X-ray impression: acute displaced mid left clavicle fracture and left shoulder X-ray impression: acute left clavicle fracture, subacutely healing humeral neck fracture. A review of the discharge summary from the hospital dated 12/22/19 at 1:29 AM revealed clavicle fracture. A review of the Minimum Data Set (MDS) Quarterly Comprehensive assessment dated [DATE] revealed Resident #24 required extensive assistance for transfers. An interview was conducted with Staff K, CNA on 02/12/20 at 10:12 AM. She stated that Resident #24 was sliding down in her chair. She called for assistance, another CNA, then grabbed the resident under her arms, one person on each side and pulled her back up in her chair. She stated the resident said aye as we were sitting her back in the chair. She didn't think anything of it because the she would say aye a lot. On the day of the incident she did not have her gait belt. She further stated that she was just trained on using the gait belt and she should have used it. An interview was conducted with Staff L, CNA on 02/12/20 at 12:29 PM. She stated she was asked to help reposition Resident #24. I was asked to help reposition her as she had scooched down in her chair. We repositioned her by going to both sides of chair and reaching under her arms and pulled her up. She stated she had her gait belt with her but did not use it. An interview was conducted with the Director of Nursing Services (DON) on 2/12/20 at 2:00 PM. She confirmed that staff members are to use Gait Belts for repositioning and transferring. She stated that Staff K and Staff L should have used a gait belt to reposition Resident #24. A review of the facility policy titled Gait Belt, last reviewed on 12/13/19, reads Policy. 1. It is a policy of this facility to utilize gait belts to promote safe workplace habits. 2. Minimize the risk of strain/sprain injuries to employees and ensuring resident safety. Procedure: Each CNA will have available to them a Gait Belt to utilize for each resident for whom care is given.