Every finding on record at The Wilshire Skilled Nursing and Therapy

Based on a review of the United States (U.S.) Food and Drug Administration (FDA) Food Code, observation, and interview, the facility failed to ensure waste was properly contained in dumpsters and failed to ensure 2 of 2 dumpsters observed were covered to reduce the potential for harboring insects or rodents. The deficient practice had the potential to affect all the residents in the facility. Findings included: The U.S. FDA Food Code, dated 2022, revealed, Chapter 5. Water, Plumbing, and Waste revealed, 5-501.15 Outside Receptacles, which included, (A) Receptacles and waste handling units for REFUSE, recyclables, and returnable used with materials containing FOOD residue and used outside the FOOD ESTABLISHMENT shall be designed and constructed to have tight-fitting lids, doors, or covers; and (B) Receptacles and waste handling units for REFUSE and recyclables such an on-site compactor shall be installed so that accumulation of debris and insect and rodent attraction and harborage are minimized and effective cleaning is facilitated around and, if the unit is not installed flush with the base pad, under the unit. During an interview on 06/10/2026 at 2:17 PM, the Regional Director of Operations stated that the facility did not have a policy related to keeping the dumpster area clean or keeping the dumpsters' lids closed. An observation on 06/10/2026 at 7:53 AM revealed two roll-off dumpsters located at the rear of the facility and adjacent to the facility's parking lot with both lids open. During an interview on 06/10/2026 at 1:22 PM, the Dietary Supervisor (DS) stated that she and maintenance staff were responsible for keeping the area around the dumpsters free of debris and ensuring the dumpster lids were closed. The DS stated the certified nurse aides (CNAs) and housekeeping staff also utilized the dumpsters and were reminded to close the lid after emptying trash. An observation on 06/10/2026 at 1:30 PM revealed the two roll-off dumpsters located at the rear of the facility and adjacent to the parking lot had their lids open. Broken eggshells, a partially consumed chicken drumstick, and a box resembling a pizza box were observed on the ground next to the dumpsters. During an interview on 06/11/2026 at 11:15 AM, the Director of Nursing (DON) stated that the expectation for the dumpster area was to keep it clean and the lids to be closed. She stated that recent windy conditions had caused the lids to open. She further stated that it was everyone's responsibility to ensure the lids remained closed. During an interview on 06/11/2026 at 11:08 AM, the Administrator (ADM) stated that the expectation for the dumpster area was for the side doors to the dumpsters to remain shut and lids to stay closed.

Based on facility document review, observation, interview, and record review, the facility failed to ensure resident shared bedrooms were designed and equipped to maintain full visual privacy for residents in them, which affected 4 (Residents #43, #35, #24, and #14) 4 residents identified with privacy curtain concerns. Findings included: During an interview on 06/10/2026 at 11:15 AM, the Regional Director of Operations (RDO) stated that the facility did not have a policy related to resident privacy. The facility's undated Resident's Right's and Family Handbook revealed Federal Resident Rights, which included You have the right to privacy, as well as private telephone calls, meetings and mail. 1. A quarterly Minimum Data Screening Assessment (MDS), with an Assessment Reference Date (ARD) of 04/24/2026, indicated that the facility admitted Resident #43 on 02/16/1999. The MDS revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. Per the MDS, the resident had active diagnoses that included anxiety disorder and depression. A quarterly MDS, with an ARD of 04/24/2026, indicated that the facility admitted Resident #35 on 06/19/2013. The MDS revealed that the resident had a BIMS score of 15, which indicated the resident had intact cognition. Per the MDS, the resident had active diagnoses that included anxiety disorder and depression. An observation of Resident #43's and Resident #35's shared bedroom on 06/09/2026 at 10:13 AM revealed the room had a partial privacy curtain. The privacy curtain separated Bed A from Bed B and ran from the wall between the two heads of the beds to the end of both residents' beds, stopping approximately 4 feet before reaching the opposite wall. The approximate 4-foot gap between the end of the curtain and the wall closest to the foot of the beds allowed each resident's sleeping area to be visible from inside the room. A mirror approximately 3 feet high by 3.5 feet wide was adhered to the opposite wall of both residents' beds, which allowed a view of each residents' sleeping area. There was no wrap around capability of the privacy curtain that was in the room for either bed. During an interview on 06/09/2026 at 10:17 AM, Resident #43 stated that they resided in a shared bedroom on the 200 Hall and that they were assigned the bed nearest to the window (Bed B). Resident #43 stated that when they left their bedroom and passed their roommate's bed (Bed A), they lowered their head and looked at their wheelchair wheels, so they did not look at their roommate. Resident #35 was not available for interview during the survey. 2. An annual Minimum Data Screening Assessment (MDS) with an Assessment Reference Date (ARD) of 04/03/2026, revealed the facility admitted Resident #24 on 04/12/2025. The MDS revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Per the MDS, the resident had active diagnoses that included schizophrenia. A quarterly MDS, with an ARD of 04/02/2026, revealed the facility admitted Resident #14 on 12/29/2006. The MDS revealed the resident had a BIMS score of 8, which indicated the resident had moderate cognitive impairment. Per the MDS, the resident had active diagnoses that included anxiety, depression, and schizophrenia. An observation of Resident #24's and Resident #14's shared bedroom on 06/08/2026 at 10:59 AM revealed the room had a partial privacy curtain. The privacy curtain separated Bed A from Bed B and ran from the wall between the two heads of the beds to the end of both residents' beds, stopping approximately 4 feet before reaching the opposite wall. The approximate 4-foot gap between the end of the curtain and the wall closest to the foot of the beds allowed each resident's sleeping area to be visible from inside the room. A mirror approximately 3 feet high by 3.5 feet wide was adhered to the opposite wall of both residents' beds, which allowed a view of each residents' sleep area. There was no wrap around capability of the privacy curtain that was in the room for either bed. During an observation and concurrent interview on 06/09/2026 at 10:20 AM, Resident #24, who was assigned to Bed A, exited the shared bathroom and walked past Bed B's bedroom area while returning to their bedroom area. Resident #24 stated that they could see their roommate's bedroom area whenever they entered or exited the shared bathroom. Resident #14 was not interviewed due to their level of cognition. During an interview on 06/10/2026 at 8:56 AM, Certified Nurse Aide (CNA) #7 stated that she was usually assigned to the 200 Hall and was familiar with the needs of the residents residing in that hall. CNA #7 stated that the process to ensure residents were provided privacy included pulling the privacy curtain. CNA #7 stated that it was impossible to provide privacy to Residents #43, #35, #24, and #14 due to the lack of a full wrap around curtain and the mirror placement on the wall in their rooms. During an interview on 06/10/2026 at 9:17 AM, Certified Medication Aide (CMA) #8 stated that she worked both 100 Hall and 200 Hall and was familiar with resident care needs. CMA #8 stated that if either resident in a shared bedroom had a visitor, the staff asked the visitor to leave the room while they administered medication. CMA #8 further stated that if the resident assigned to Bed A needed to use the shared bathroom, the resident in Bed A would have a view of Bed B's sleeping area while crossing the room to enter or exit the bathroom. CMA #8 stated that the large mirror placement also provided residents and/or visitors in the room with a full view of each resident's sleep area. During an interview on 06/10/2026 at 9:36 AM, the Director of Nursing (DON) stated that the expectation for providing residents' privacy was to pull the curtain across the room. She stated that depending on the direction of placement of the head and foot of the beds, residents of a shared room had the capability of viewing their roommate's area. The DON stated that the resident assigned to Bed B could not take a nap without being seen by their roommate and/or their visitors. The DON stated that it would be impossible to provide privacy to both residents while they received care. The DON further stated that all resident bedrooms were structured the same way with the mirror placement, curtain length, and placement. During an interview on 06/10/2026 at 10:00 AM, the Administrator (ADM) stated that the expectation for providing residents' privacy was that privacy curtains in resident rooms should be used. The ADM stated that the process of providing residents with privacy included knocking on the door and pulling the privacy curtain. The ADM stated that the privacy curtain divided the room by running across the middle of the room between the two beds. The ADM also stated that if the resident assigned to Bed A wanted to use the shared bathroom, they would have to cross Bed B's area, which would allow a full view of the resident assigned to Bed B.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure a resident's nails were kept clean and trimmed for 1 (Resident #3) of 1 resident reviewed for activities of daily living (ADLs) care. Findings included: A facility policy titled, Nursing Skills Guideline, revised 03/2025, indicated, Assistance with activities of daily living will be provided in a manner that prioritizes the resident's comfort, safety, and personal preferences. An admission Record revealed the facility admitted Resident #3 on 01/09/2026. According to the admission Record, the resident had a medical history that included diagnoses of legal blindness and sequelae of cerebral infarction (long-term condition or complications as a result of a stroke). A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/08/2026, revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS indicated that Resident #3 required substantial/maximal assistance with personal hygiene. Resident #3's Care Plan Report, included a focus area initiated 01/26/2026, that indicated the resident had an ADL self-care deficit related to limited mobility, impaired cognition, and incontinence. An undated intervention directed staff to check the resident's nail length on bath days and report concerns to the nurse. Resident #3's nail care record for the timeframe, from 05/12/2026 through 06/10/2026, indicated that staff documented that Resident #3 received nail care 61 times. The record did not indicate what Nail care was provided. During a concurrent observation and interview on 06/08/2026 at 1:30 PM, Resident #3's nails on both hands were noted to be untrimmed and dirty underneath. Resident #3 stated they asked staff to cut their nails, but staff did not do it. The resident stated they did not like their nails being long in length. During a concurrent observation and interview on 06/10/2026 at 8:55 AM, Resident #3's nails were observed to still be long. Resident #3 stated their nails had not been trimmed and that they still wanted them trimmed. During an interview on 06/10/2026 at 11:26 AM, Certified Nurse Aide (CNA) #7 stated that she was aware of Resident #3's nail length and had not reported it to the nurse. She stated that she had cleaned the resident's nails on 06/08/2026 but did not trim them. During an interview on 06/10/2026 at 1:45 PM, CNA #7 stated that when she documented in Resident #3's nail care task record that the task had been completed, it indicated she had only cleaned the nails. She stated that she did not trim the nails. During an interview on 06/10/2026 at 1:39 PM, Licensed Practical Nurse (LPN) #2 observed Resident #3's nails and stated that the nails should have been filed at the length they were at. She stated the resident's left thumb nail was broken and chipped. During an interview on 06/10/2026 at 1:49 PM, the Director of Nursing (DON) measured Resident #3's nails. She stated that the longest nail on the right hand was the thumb at 0.5 centimeters (cm) and the longest nail on the left hand was the ring finger at 0.4 cm. She stated that a couple of the nails were broken and the nails were long. She stated her expectation was that nails be trimmed during showers when nails were softened. She stated that it was the resident's right to have the nails shorter if the resident wanted shorter nails. During an interview on 06/11/2026 at 10:21 AM, the Administrator stated his expectation for nail care was that it be provided if needed. He stated his expectation was that Resident #3 should have had nails trimmed with the resident's showers, and the nails should have been neat and clean.

Based on facility policy review, record review, and interview, the facility failed to ensure that prompt efforts were made to resolve grievances with regard to missing property, which affected 1 (Resident #27) of 2 residents reviewed for personal property concerns. Findings included: A facility policy titled, Resident/Family Grievances, revised 03/03/2020, revealed, The facility promotes an atmosphere in which the resident/family has a right to voice grievances without discrimination or reprisal. Resident/Family grievances could include treatment, funds, lost items or violation of rights. The facility will attempt to work with resident/family to resolve grievances promptly. The policy revealed, Any grievance from resident/family should be recorded on a Grievance Log (NRSG-O02-G). Grievance Log should be updated and reviewed in the Q2 meeting and a designee will be assigned to call or follow-up on the grievance using the To Do List (NRSG-062-H). The Designee will document any follow-up contact on the Grievance Log and discuss any resolution in the Q2 meeting. Resident/Records/Care Plans will be updated if needed with any contact or changes. During an interview on 06/10/2026 at 2:05 PM, the Regional Director of Operations (RDO) stated that the facility did not have a policy for personal property or missing property. An admission Record revealed the facility admitted Resident #27 on 05/13/2025. According to the admission Record, the resident had a medical history that included diagnoses of stage 3A chronic kidney disease and morbid (severe) obesity due to excess calories. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/08/2026, revealed Resident #27 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS indicated that the resident did not experience hallucinations (perceptual experiences in the absence of real external sensory stimuli) or delusions (misconceptions or beliefs that are firmly held, contrary to reality). Resident #27's Care Plan Report, included a focus area revised 10/22/2025, that indicated the resident had the potential for poor activity involvement related to a decrease in interest. Interventions directed staff that Resident #27 preferred self-directed activities such as watching movies and television shows and talking on the phone (revised 05/24/2026). During an interview on 06/08/2026 at 10:45 AM, Resident #27 stated that two Mondays prior, they (Resident #27) left a phone charging and when they returned from a shower, the phone was missing. During an interview on 06/10/2026 at 11:06 AM, Certified Nurse Aide (CNA) #10 stated that a couple of weeks prior, Resident #27 told her that their phone went missing, so she reported it to a nurse. During an interview on 06/10/2026 at 11:16 AM, CNA #7 stated Resident #27 told her a few weeks ago that the resident's phone was missing. She stated she reported it to the Director of Nursing (DON). During an interview on 06/10/2026 at 11:30 AM, the DON stated that staff had not reported to her that Resident #27 was missing a phone. During an interview on 06/10/2026 at 11:46 AM, the DON stated that her expectation was that staff report missing property as soon as possible to the charge nurse or the Abuse Coordinator. During an interview on 06/11/2026 at 12:14 PM, the Administrator stated that Resident #27's phone had been found. He stated it had been in the medication room because the staff did not know who the phone belonged to. He stated that he did not know who found the phone. During an interview on 06/11/2026 at 4:27 PM, Resident #27 stated the Administrator brought their cell phone to them that day (06/11/2026). The resident stated that they (Resident #27) did not know when it had been found. During an interview on 06/10/2026 at 11:33 AM, the Administrator stated that he was the Abuse Coordinator. He stated that a missing phone for Resident #27 had not been reported to him. He stated that his expectation was that staff search for the missing item and if not found, then report immediately to him.

Based on interview, record review, and facility policy review, the facility failed to ensure staff followed physician orders with regard to laboratory testing, dressing changes, and application of ice packs, which affected 1 (Resident #50) of 14 sampled residents. Findings included: A facility policy titled, Skin and Wound Care Guidelines Skin Integrity/Wound Care, revised 07/2024, indicated, 4. Current Treatment, which specified, Medical treatments will be ordered by a physician or their designee. The policy revealed, 7. The nurse who identifies areas of skin breakdown should complete the following, which included Notify the attending provider; and Obtain a treatment and initiate. The policy further indicated, 11. A multidisciplinary plan of care will be implemented that reflects intervention strategies designed to alleviate, reduce, or minimize the negative effects of each resident's identified risk factors, and manage and treat existing pressure ulcers. Care plan to be implemented by the charge or staff nurse, *Document appropriate interventions on falling stars. An admission Record revealed the facility admitted Resident #50 on 02/28/2025. According to the admission Record, the resident had a medical history that included a diagnosis of aftercare following joint replacement surgery. The admission Record indicated that the facility discharged the resident on 03/02/2025. A five-day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/02/2025, revealed that Resident #50 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. During a phone interview on 06/10/2026 at 1:24 PM, Resident #50 stated the facility staff did not draw ordered laboratory tests, change the surgical dressing, or provide ice packs as ordered during their stay at the facility. Resident #50 stated that they abruptly left the facility due to concerns about safety and lack of care. Resident #50's Order Summary Report, with active orders as of 03/02/2025 contained the following orders:- Laboratory testing, including a complete blood count (CBC), comprehensive metabolic panel (CMP), and prealbumin, to be completed upon admission, with an order date of 02/28/2025.- Clean the resident's surgical incision twice daily with peroxide and change dressing daily and as needed (PRN), with an order date of 02/28/2025.- Apply ice packs every four hours and PRN for pain, with an order date of 03/01/2025. Resident #50's clinical record and facility documentation revealed no evidence of completion of the ordered laboratory tests, dressing changes, or application of ice packs. During an interview on 06/12/2026 at 2:20 PM, the Director of Nursing (DON) stated staff were expected to follow provider orders. The DON reviewed Resident #50's clinical record and stated that there was no documented evidence that the orders were completed. She stated that the expectation was that laboratory orders upon admission were to be completed within 72 hours. During an interview on 06/12/2026 at 12:15 PM, the Administrator stated staff were expected to carry out physician orders or notify the provider if unable to do so. The Administrator stated that failure to carry out ordered treatments represented a failure in care and may have contributed to the resident's decision to leave the facility.

Based on facility policy review, facility document review, record review, and interview, the facility failed to ensure 1 (Resident #6) of 3 residents reviewed for beneficiary notification requirements was provided a Notice of Medicare Non-Coverage (NOMNC) and a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) prior to the end of covered Medicare Part A services. Findings included: The facility's undated Resident's Rights and Family Handbook included a document titled, Licensed Nursing Facility's Policy Statement Regarding Residents' Right to Self-Determination, which revealed, 1. It is our policy to follow the directions of our Residents who have the capacity to make decisions to the extent allowed by law. You will be considered to have capacity to make health care decisions unless unconscious, determined to be incompetent by a court of law, or medically determined by your attending physician to be unable to make health care decisions. An admission Record revealed the facility admitted Resident #6 on 02/02/2024. According to the admission Record, the resident had a medical history that included diagnoses of unspecified disorder of adult personality and behavior and mood disorder due to known physiological condition with major depressive-like episode. The admission Record indicated that the resident was their own responsible party for finances. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/25/2026, revealed Resident #6 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident had moderate cognitive impairment. Resident #6's Care Plan Report included a focus area initiated 02/13/2024, that indicated the resident had impaired cognitive function as evidenced by their fluctuating BIMS score. Interventions indicated that the resident's BIMS score was 9, which indicated the resident had moderate cognitive impairment (revised 05/10/2026). Interventions directed staff to engage the resident in simple structured activities that avoided overly demanding tasks (initiated 12/13/2024). Resident #6's Notice of Medicare Non-Coverage, dated 05/22/2026, revealed Medicare coverage of the skilled services would end on 05/24/2026 and financial liability would begin on 05/25/2026. The document revealed that additional information written by Assistant Director of Nursing (ADON)- Licensed Practical Nurse (LPN) #4 indicated that the resident was unable to understand the NOMNC due to a cognitive deficit, indicating that the resident had a BIMS score of 9. The NOMNC further revealed that the Administrator (ADM) was notified via phone. The document revealed the signature section for the resident or their representative acknowledging receiving and understanding the notice was left blank. Resident #6's undated Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage revealed that beginning on 05/25/2026, the resident may have to pay out of pocket for care provided at the facility if the resident did not have other insurance that may cover the costs. The document indicated that Option 3 was selected and reflected that the resident did not want the care and understood that they were not responsible for paying and would forgo the appeal process to see if Medicare would pay. The document revealed that additional information was handwritten and signed by ADON-LPN #4 that the resident was unable to understand the form due to a cognitive deficit, and that the ADM was notified via phone on 05/22/2026. The document revealed the signature area at the bottom of the page for patient or authorized representative acknowledging receiving and understanding the notice was left blank. During an interview on 06/10/2026 at 3:08 PM, ADON-LPN #4 stated that she completed Resident #6's NOMNC and ABN notices. She stated that if a resident was cognitively able, they signed the forms. She stated that if the resident had a cognitive deficit and had an assigned representative, the representative was contacted, and the form was explained. She stated that if the resident had a cognitive deficit, did not understand the form, and had no representative, she explained the case to the ADM, who would become the resident's representative, and the resident would become a trust patient. During the interview with ADON-LPN #4, the Regional Nurse Consultant stated that the Director of Skilled Services and Clinical Reimbursement (DSSCR) was responsible for the trust designation and process. During a phone interview on 06/10/2026 at 4:00 PM, the DSSCR stated that if a resident had a cognitive deficit, did not have family, and was not an Adult Protective Services (APS) case, the resident was designated as a trust patient, which was handled by the ADM and/or the Business Manager. She stated that she did not know the process of becoming a trust patient. During an interview on 06/10/2026 at 4:11 PM, the ADM revealed that if a resident could not make decisions and did not have family or another representative, then he assigned himself as the decision maker and was responsible for signing forms on the resident's behalf. The ADM stated that the only resident he was assigned as decision maker at the time of the survey was Resident #6. The ADM stated that he was not officially the resident's representative and not legally capable of making decisions to consent to treatment, such as surgery. He stated that due to the resident's designation as a trust patient, he was responsible for Resident #6's managing monthly stipends related to the facility trust fund accounts. Per the ADM, Regarding the NOMNC and ABN notice, therapy staff deemed the resident met their maximum potential, and he did not feel it was ethical to continue therapy services and bill Medicare for services that were of no benefit to the resident. He stated that ADON-LPN #4 notified him by phone because Resident #6 was coming off skilled nursing services, and he only needed to be made aware of the situation and did not need approval or a signature for the form. He stated that the resident did not fully understand the NOMNC or ABN notice and/or the three options for Medicare billing for care, room, and board. The ADM stated that he did not make a decision for Resident #6's Medicare billing and did not sign the NOMC on behalf of the resident. During an interview on 06/11/2026 at 9:23 AM, the ADM stated that he was not the legal representative for Resident #6. The ADM stated that if a resident could not understand a form and had no representative, the resident's physician would be required to make the resident's decisions. The ADM stated that ADON-LPN #4 notified him by phone because Resident #6 was coming off skilled services and LPN #4 was only to provide notification and there was no need to sign anything.

Based on observation, record review, and interview, the facility failed to ensure all drugs and biologicals were stored properly for two (#7 and #8) of two sampled residents whose medications were observed not to be stored according to company policy and procedure. The administrator identified 26 residents resided in the facility. Findings: A Storage of Medications policy, dated 01/2022, read in part, Medications and biologicals are stored safely, securely, and properly, following manufactuers' recommendations or those of the supplier. The medications supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. On 11/22/24 at 11:10 a.m., medication cart #1, located on the west hall, was observed to be unattended. Res #7's metformin 500 mg (diabetic medication) was observed on top of the medication cart. On 11/22/24 at 11:11 a.m., medication cart #1, located on the west hall, was observed to be unattended. Res #8's clonidine 0.1 mg (blood pressure medication) and sevelamer 800 mg (phosphate binder) was observed on top of the medication cart. On 11/22/24 at 11:12 a.m., CMA #1 reported they could not leave the medication carts unattended. On 11/22/24 at 3:20 p.m., the DON reported they were to have all medications stored properly.

Based on observation, record review and interview, the facility failed to ensure: a. expired foods were removed from circulation; b. the kitchen was kept clean and in good repair; and c. leftover reheated soup reached an internal temperature of 165 degrees Fahrenheit. The administrator identified 28 residents resided in the facility. Findings: An undated Weekly Cleaning Schedule, documented the refrigerator, and the wall behind the back and front door to the kitchen were to be cleaned weekly to include the bottom of the refrigerators and freezers. On [DATE] at 10:54 a.m., the initial tour of the kitchen was conducted with the CDM. On [DATE] at 11:03 a.m., a carton of nectar thickened tea in the refrigerator was dated [DATE] with a best used by date of [DATE]. The CDM stated the policy for food storage was to label, date, and rotate. On [DATE] at 11:05 a.m., the CDM stated the thickener was expired. On [DATE] at 11:13 a.m., the dry storage area had five more cartons of the same thickener with the same best used by date of [DATE]. The CDM stated they must have gotten lost as they do not use thickener much. They stated there was a whole case that was expired since they were the same date and they came in a box of six. On [DATE] at 11:16 a.m., the freezer next to the desk in the office had dark areas and debris on the bottom floor of the freezer. On [DATE] at 11:18 a.m., the CDM stated the freezer was wiped down a few weeks ago. They stated they had a schedule and the freezer needed to be cleaned. On [DATE] at 9:57 a.m., a second tour of the kitchen conducted and observations were made. On [DATE] at 10:13 a.m., the window seal located behind the clean side of the dishwasher had a large amount of brown dust and debris. The window blinds were broken. On [DATE] at 10:16 a.m., the CDM stated the window seal was not clean. On [DATE] at 11:24 a.m., the CDM was observed to microwave a bowl of soup that had a date of ,d+[DATE]. They then placed it on the hall tray cart. On [DATE] at 11:27 a.m., the hall tray cart left the kitchen. The CDM was asked what temperature did they reheat the leftover soup to. They stated they forgot to temp it. The CDM went to get the tray off the cart and took a temperature. They temperature was 127 degrees Fahrenheit.

Based on observation, record review and interview, the facility failed to ensure scheduled activities were held. The administrator identified 28 residents resided in the facility. Findings: An undated facility Resident Rights and Family Handbook, read in part, .We have a full program of social, intellectual, recreational, creative and religious activities available to residents at our Center. The variety of activities offers something of interest to everyone. A calendar of monthly events is posted in a convenient location . The September 2024 Activity Calendar documented on 09/18/24 the facility was to have exercise at 9:00 a.m. and cup pong at 10:00 a.m. 1. Resident #24 had diagnoses which included muscle weakness and multiple sclerosis. An Admission Resident Assessment, dated 04/16/24, documented it was very important for Resident #24 to do things with groups of people and it was very important for them to do their favorite activities. A Quarterly Resident Assessment, dated 07/17/24, documented Resident #24's cognition was intact. On 09/17/24 at 1:50 p.m., Resident #24 stated they used to participate in activities when the previous staff member was employed and doing activities. They stated now they just stayed confined to their room. They stated the activities person left around a couple months ago. 2. Resident #20 had diagnoses which included acute kidney failure and type two diabetes mellitus. An Admission Resident Assessment, dated 07/01/24, documented Resident #20's cognition was moderately impaired. It documented it was very important for Resident #20 to do things with groups of people and it was very important for them to do their favorite activities. On 09/17/24 at 12:08 p.m., Resident #20 stated they used to participate in the activity program, but the facility did not have an activity director now. They stated it had been close to a month since they had an activity director. 3. Resident #22 had diagnoses which included major depressive disorder, anxiety, and left hemiparesis following cerebral infarct. An Admission MDS Assessment, dated 9/21/23, documented activity preferences as somewhat important for having reading material, music, and favorite activities. It documented activity preferences as very important for animals, news, being around groups of people, going outside when the weather was good, and religious services. A Quarterly MDS Assessment, dated 6/19/24, documented the resident was cognitively intact with a BIMS score of 15. On 09/17/24 at 1:57 p.m., the September 2024 activities calendar was observed on the wall in Resident #22's room. On 09/17/24 at 2:36 p.m., Resident #22 stated they do not do activities at all. They stated the activities person had been gone for about a month. They stated they had some activities when they were there. They stated since they had been gone no one else did the activities. They stated they would like to go outside and smoke because they were tired of just looking at the walls all the time. On 09/18/24 at 8:26 a.m., the administrator stated they had not had an activity director for about a month. On 09/18/24 at 9:20 a.m., there were no scheduled activities observed taking place in the facility. There were three residents sitting in the front sitting area by the front doors watching television. Behind the residents were four corporate staff members and the pharmacist sitting at tables. There were no observations the 9:00 a.m. scheduled exercise activity took place. On 09/18/24 at 10:42 a.m., there had been no observations the 10:00 a.m. scheduled cup pong activity took place. On 09/18/24 at 2:35 p.m., a meeting was held with the Resident Council group. They stated they used to have an activity program at the facility. They stated now they didn't necessarily have activities. They stated the activity person left about three weeks ago, and ever since, they had not had activities. On 09/19/24 at 12:41 p.m., CNA #1 stated when they first came to the facility they had a great activity program. CNA #1 stated they had not seen any scheduled activities taking place this week. They stated there was not a scheduled person in that department right now. They stated even when the facility had an activity director, they would often times get pulled to do other things. They stated the facility needed an activity program to Keep the residents living and lively. On 09/19/24 at 1:00 p.m., the administrator stated normally the activity program had a monthly calendar they passed out to the residents. They stated the facility would announce scheduled activities, and staff would go around and notify the residents, and bring them to the activity when they wanted to participate. The administrator stated they were responsible for ensuring activities took place. On 09/19/24 at 1:01 p.m., the administrator stated the scheduled activities for 09/18/24 did not occur because One we didn't have and activity director, and two I was just so busy. They stated they were trying to get people hired. 45583

Based on observation, record review, and interview, the facility failed to ensure Resident Council meetings were held. The administrator identified 28 residents resided in the facility. Findings: The facility Resident Rights and Family Handbook, undated, read in part, .The Resident Council is designed to give residents and family members a regular opportunity to participate in the planning of future activities and events. The Resident Council meeting also provides a forum to exchange ideas and socialize with people facing similar challenges. Resident Council meetings are scheduled monthly on the activity calendar . The September 2024 Activity Calendar documented a Resident Council meeting was scheduled on 09/18/24 at 2:00 p.m. On 09/18/24 at 8:25 a.m., the Resident Council president stated they took over a Resident Council president four weeks ago. They stated they thought there was a Resident Council meeting scheduled, but they had not heard when. On 09/18/24 at 8:26 a.m., the administrator stated they were the person responsible for Resident Council because the facility did not have an AD. They stated they had not had an activity director for about a month. On 09/18/24 at 1:58 p.m., the DON was observed searching for the Resident Council meeting book. They stated the facility did not have a social service person because they had quit two to three weeks ago. The Resident Council meeting book did not contain meeting information for July or August 2024. On 09/18/24 at 2:02 p.m., the administrator stated the facility held a Resident Council meeting in July. They stated the facility did not hold a meeting in August because they Couldn't get anyone to do the Resident Council President. The administrator stated the facility would not have held a Resident Council meeting because they didn't have a Resident Council president. They stated the new Resident Council president had agreed to the position this past Monday. They stated the previous Resident Council president left the faciity on [DATE] and the new Resident Council president admitted to the facility on [DATE]. The administrator stated they could not validate a meeting was held in July because they did not have any paperwork. They stated a meeting was not held in August 2024. On 09/18/24 at 2:14 p.m., no Resident Council meeting was observed taking place. On 09/18/24 at 2:35 p.m., a meeting was held with the Resident Council group. The Resident Council group stated they did not know when the next Resident Council meeting was scheduled and were unable to identify when the last Resident Council meeting was held. They stated it was held when the precious activity person was employed. On 09/19/24 at 12:58 p.m., the administrator stated residents were notified of the scheduled Resident Council meetings on the activity calendar that was posted in each resident room. They stated the activity director would go to each resident room notifying them of the day and time of the meeting. The administrator stated all staff were responsible for getting residents up and to the meetings. On 09/19/24 at 1:01 p.m., the administrator stated the scheduled Resident Council meeting for 09/18/24 did not occur because One we didn't have and activity director, and two I was just so busy. They stated they were trying to get people hired.

Based on observation, record review and interview, the facility failed to ensure: a. urine in a hat was covered to prevent cross contamination when it was transported down a resident hall; and b. a container holding urine was cleaned prior to placing it back into the resident's room for one (#4) of one sampled resident whose urine was observed being transported down the hall. The ADON identified six residents who utilized urinals. The Roster Matrix, dated 09/17/24, documented one resident with a urinary catheter. Findings: Resident #4 had diagnoses which included neuromuscular dysfunction of the bladder. A Quarterly Resident Assessment, dated 08/17/24, documented Resident #4 had an indwelling catheter. On 09/19/24 at 8:40 a.m., CNA #1 was observed asking the DON about enhanced barrier precautions with Resident #4. They asked the DON if they were allowed to wear the yellow gown to dump urine down the hall. The DON stated staff were to take the gown off. The DON stated staff were ok to carry the urine out. The DON stated, Make sure it is in the bag. On 09/18/24 at 8:43 a.m., CNA #1 was observed transporting a hat that contained urine from Resident #4's room down the hall into the powder room on Hall 100. The CNA dumped the urine in the toilet, flushed the toilet, and placed the hat in a plastic bag in the resident's room. The CNA placed the bag in a cabinet in the resident's room, removed their gloves, and sanitized their hands. The CNA did not clean the hat prior to placing it back in the resident's room. The CNA did not cover the urine to transport the open hat down the hall. On 09/18/24 at 8:45 a.m., CNA #1 stated they did not use a bag to transport the urine down the hall. They stated they did place the hat in a bag when they brought it back to the room. They stated the hat was not rinsed out before placing it back in the resident's room. They stated it was the first time they had used a hat to transport urine. They stated usually they had a urinal to transport it. CNA #1 stated they were usually on the other hall and would use the hose in the whirlpool room to rinse it out. On 09/18/24 at 12:01 p.m., the DON stated when urine was transported from a resident's room to the powder room it should be in a bag. They stated the container should be placed in a plastic bag in the resident's room after use.

Based on observation and interview, the facility failed to ensure posted staffing information, which included the facility name, date, actual hours worked for RNs, LPNs, CMAs, and CNAs, and the resident census was updated. The administrator identified 28 residents resided in the facility. Findings: On 09/17/24 at 12:14 p.m., an observation was made of the posted staffing on the wall at the beginning of hall 200 which included the name of the facility, census of 29, and the names of each staff for each shift. It did not include the hours for each licensed staff and did not have RN hours. On 09/18/24 at 8:18 a.m., an observation of the posted staffing on the board on hall 200 still had the date of 9/17/24, census of 29, and the staff for each shift. It did not have the total hours for any discipline. On 09/19/24 at 9:52 a.m., an observation of posted staffing at the beginning of both hall 100 and 200 was made which included the name of the facility, census, date of 9/17/24, and each shift assignment. It did not include the total hours for licensed staff and had not been updated. On 9/19/24 at 9:57 a.m., the administrator stated they were aware of the posted staffing regulation. They stated it was to include who the nurse, CNA, and CMA was, and what hall they were working for each shift. They stated it was located on each hall and updated every night. On 09/19/24 at 10:26 a.m., the administrator observed the posted staffing board on hall 100 and stated the required information was not present. They stated it did not have the correct date. They stated they did not know of the requirements.

Based on record review and interview, the facility failed to update a care plan for smoking for one (#24) of 13 sampled residents reviewed for care plan updates. The administrator identified two residents who smoked resided in the facility. Findings: An undated Smoking List, documented two residents who smoked. Resident #24 was not on the list. 1. Resident #24 had diagnoses which included muscle weakness and multiple sclerosis. A Smoking/Vaping Supervision Checklist, dated 06/29/24, documented Resident #24's smoking privileges had been revoked due to serious safety issues to self, other elders, and the facility as a whole. A Quarterly Resident Assessment, dated 07/17/24, documented Resident #24's cognition was intact. It did not document current tobacco use. A Care Plan, revised 08/14/24, documented the resident was a smoker and was at risk for smoking related injuries and health complications. It documented a goal for the resident's safety to be maintained through the next review date. On 09/17/24 at 1:50 p.m. Resident #24 stated they were no longer allowed to smoke at the facility. On 09/19/24 at 1:17 p.m., the administrator stated Resident #24 was no longer smoking. They stated the resident was offered nicotine patches. On 09/19/24 at 2:14 p.m., the corporate MDS consultant stated they were responsible for resident care plans. They stated care plans were updated after quarterly and annual assessments and 21 days from admission. On 09/19/24 at 2:15 p.m., the corporate MDS consultant reviewed Resident #24's care plan and stated there was a care plan for the resident's smoking. They stated it did not document the resident's smoking privileges were no longer in effect. They stated since they had just now been informed the resident was no longer a smoker, they would have to update the care plan. On 09/19/24 at 2:17 p.m., the corporate MDS consultant entered the DON's office to identify when the resident's smoking privileges were no longer in effect. The DON stated 06/29/24 was the day the resident stopped being able to smoke cigarettes.

Based on record review and interview the facility failed to ensure a physician was notified when a medication was held for one (#24) of five sampled residents reviewed for unnecessary medications. The administrator identified 28 residents resided in the facility. Findings: A Physician Notification of Change policy, dated 12/01/09, read in part, .The facility will .consult with the resident's physician .of the following events .A need to alter treatment significantly .commence a new form of treatment . A Medication Administration policy, dated 01/22, read in part, .If a dose of regularly scheduled medication is withheld .not available .An explanatory note is entered .If [two] consecutive doses .of a vital medication are withheld .or not available the physician is notified. Nursing documents the notification and physician response . Resident #24 had diagnoses which included muscle weakness and multiple sclerosis. A Physician Order, start date 04/06/24, documented Aubagio (pyrimidine synthesis inhibitor) 14 mg tablet give one tablet by mouth one time a day related to multiple sclerosis. It documented the medication was on hold. The April 2024 MAR documented the Aubagio was administered on the 6th, 7th, and 8th. It documented the medication was held for the rest of the month. The May 2024 MAR documented the Aubagio was held for the month. The June 2024 MAR documented the Aubagio was held for the month. The July 2024 MAR documented the Aubagio was held for the month. The August 2024 MAR documented the Aubagio was held for the month. The September 2024 MAR documented the Aubagio was held for the month. There was no documentation the facility notified Resident #24's physician prior to the medication being placed on hold. On 09/23/24 at 2:31 p.m., LPN #1 stated on April 5th there was a note written on a pharmacy note that insurance would not cover the medication because it was $120 per month. LPN #2 stated pharmacy had written a note on their end under profile. LPN #2 stated the nurse was supposed to call the doctor to change the order. LPN #2 stated they could not find any progress note of the physician being notified. On 09/23/24 at 2:33 p.m., LPN #2 stated they had called the facility pharmacy to identify this information. LPN #2 stated if a medication was not available to administer, they would notify the DON to see if they would approve the cost. They stated if the facility would not approve the cost, they would notify the physician. They stated they would then call the pharmacy back and put a note in. They stated they would also notify the family. On 09/23/24 at 2:43 p.m., the DON stated, I put the hold order on there. They stated the revision date was 04/05/24 and the start hold date was 04/06/24. On 09/23/24 at 2:45 p.m., the DON reviewed resident #24's record and stated they did not find any documentation or a nurse note for the reason the medication was on hold or if the physician was notified of the medication being on hold. On 09/24/24 at 12:20 p.m., Regional Nurse Consultant #1 provided a form from pharmacy related to Resident #24's Aubagio. They stated they did not locate any documentation of the physician being notified when the medication was put on hold. They stated the physician had signed monthly orders that documented the medication was on hold. The form from pharmacy, dated 04/05/24, documented the nurse would call the physician. It documented insurance wound not cover. There was no documentation the physician was notified of the medication not being covered by insurance.

Based on record review and interview, the facility failed to complete a nurse aide performance review once every 12 months for one (CMA #1) of five employee files reviewed. The DON identified 31 residents resided in the facility. Findings: An employee list documented 23 staff members for the facility. Findings: CMA #1 had a hire date of 01/30/04. There was no CNA annual competency reviewed located in the employees file. On 06/13/24 at 1:58 p.m., the BOM stated there was no annual competency for CMA #1.

Based on record review and interview, the facility failed to provide baths for three (#1, 2, and #3) of three sampled residents reviewed for ADL assistance. The DON identified 29 residents who required assistance with ADLs resided in the facility. Findings: 1. Resident #1 had diagnoses which included hemiplegia and fibromyalgia. Resident #1's quarterly assessment, dated 05/23/24, documented Resident #1's cognition was intact. Resident #1's care plan for ADL's revised on 02/06/24, documented, a. bathing required transfer assist of one staff. b. scheduled bath days - Monday, Wednesday, and Friday on the day shift on the 6 a.m. to 2 p.m. shift. On 06/12/24 at 12:31 p.m., Resident #1 stated they hadn't received a bath since last week. A review of Resident #1's bathing task documented the resident had not received a bath, five out of 13 opportunities. No bath was documented on 05/15/24, 05/17/24, 05/20/24, 05/22/24, and 05/24/24. 2. Resident #2 had diagnosis which included, hemiplegia and hemiparesis following cerebral infarction.Resident #2's quarterly assessment, dated 03/19/24, documented Resident #2's cognition was intact. Resident #2's care plan for ADL's revised on 10/02/23, documented bathing required assist of one staff participation. On 06/12/24 at 12:15 p.m., Resident #2 stated sometimes we get baths. A review of Resident #2's bathing task documented the resident had not received a bath seven out of 13 opportunities. No bath was documented on 05/21/24, 05/23/24, 05/25/24, 05/28/24, 05/30/24, 06/04/24, and 06/11/24. 3. Resident #3 had diagnoses which included acute and chronic diastolic (congestive) heart failure and chronic kidney disease. Resident #3's quarterly assessment, dated 05/14/24, documented Resident #3's cognition was intact. Resident #3's care plan for ADL's revised on 09/20/22, documented bathing required supervision. On 06/12/24 at 11:13 a.m., Resident #3 stated their baths were scheduled two times a week on Tuesday and Saturday. They stated they often didn't get that schedule. They stated it could be up to 10 days between baths. On 06/13/24 at 10:40 a.m., the DON stated all bathing documentation was done in the EHR, there was no longer any paper documentation. On 06/13/24 at 11:43 a.m., the DON stated they had no documentation of baths for the dates listed above.

Based on record review and interview, the facility failed to guarantee the person designated to serve as the DM was certified no later than one year after hire. The Residents Census and Conditions of Residents report, dated 07/19/22, documented 30 residents resided in the facility, and two residents received tube feeding. Findings: An active employee COVID-19 vaccine status report documented the DM started employment at the facility on 02/18/15. There was no documentation the DM was certified as a dietary manager. On 07/19/22 at 7:29 a.m., the DM was asked how long they had been in their current position. They stated about two years. They were asked if they were certified as a DM. They stated they had taken classes, but had not tested . On 07/20/22 at 7:24 a.m., the administrator stated the DM was hired in their current position on 06/01/20, but started out as a PRN cook on 02/18/15.

Based on observation and interview, the facility failed to ensure food service equipment and the building was maintained clean and in good repair. The Residents Census and Conditions of Residents report, dated 07/19/22, documented 30 residents resided in the facility, and two residents received tube feeding. Findings: On 07/19/22 at 7:29 a.m., a tour of the kitchen was conducted. The following observations were made: a. there were brown and yellow stains on the ceiling tiles, b. there was an accumulation of black residue on the floor and the walls below the dish machine, c. there was an accumulation of brown residue/rust under the three compartment sink and dish machine, d. there was an accumulation of lint on the oven hood filters, e. the wood around the serve out window was unfinished/not sealed, the baseboard was loose from the wall, f. the wood on the cabinet below the hand sink was not sealed, the wood was bare, and g. there was brown residue in the wells on the steam table in the serving area. On 07/19/22 at 1:48 p.m., the DM was asked what was policy for cleaning and maintaining food service equipment and the building. They stated they cleaned daily and also had a weekly cleaning schedule. They stated they logged any maintenance issues into the computer for repairs or called the service company. The DM was made aware of the above findings.

Based on observations and interviews, it was determined the facility failed to ensure: a. a clean, sanitary, and homelike environment was maintained for one shared resident bathroom on hall 100 of three shared resident bathrooms observed. The DON (director of nurses) identified four residents utilized the shared resident bathroom on hall 100; and b. a clean, sanitary, and homelike environment was maintained for one shower room on hall 100 of two shower rooms observed. The DON identified 38 residents utilized the shower room on hall 100. Findings: On 02/26/19 at 8:30 a.m., the shared resident bathroom was observed on hall 100. There was brown and black debris on the floor, missing laminate flooring, and a strong musty odor detected. At 8:38 a.m., the shower room was observed on hall 100 with a black substance in the grout and on the tiles in the second shower stall. A strong musty odor was detected. On 02/28/19 at 11:45 a.m., the shared resident bathroom was observed on hall 100. The floor remained covered with brown and black dirt and debris. There was standing water behind the toilet and a brown ring around the base of the toilet. There were several cigarette butts inside the toilet. A strong musty odor was detected. At 11:50 a.m., the shower room was observed on hall 100. A black substance remained on the tiles and in the grout line of the second shower stall. A strong musty odor was detected. At 1:52 p.m., resident #6 stated the shared resident bathroom on hall 100 always had a wet floor and smelled like mold. At 2:00 p.m., resident #18 stated the shared resident bathroom on hall 100 always smells like mold. She said, Everyone knows that. At 2:02 p.m., CNA #1 (certified nurse aide) stated the shared bathroom on hall 100 smells. She observed the wall behind the toilet and stated she saw water behind the toilet. She said, It looks like the wall is leaking. She then observed the shower room on hall 100 with the surveyor. She stated the black substance on the tiles and in the grout line in the second shower stall looks like mold. At 2:15 p.m., the administrator observed the shared resident bathroom on hall 100 with the surveyor. He was asked if he observed water behind the toilet. He said, I see that. He then observed the second shower stall in the hall 100 shower room. He was asked if he observed a black substance in the grout line. He stated he did not. A paper towel was rubbed on the black substance. The black substance transferred to the paper towel. He said, I see that. Well looks like mold.

Based on record reviews and interviews, it was determined the facility failed to ensure antibiotics were not administered without indications for use for two (#21 and #27) of five sampled residents reviewed for unnecessary medications. The LPN (licensed practical nurse) #1/Infection Control nurse identified 12 residents were treated with antibiotics for a urinary tract infection [MEDICAL CONDITION] in the last 90 days. Findings: A facility policy titled, Antibiotic Stewardship documented: .The antibiotic stewardship program promotes the appropriate use of antibiotics .The antibiotic stewardship program will place emphasis on two areas 1) Treat only infections that need an antibiotic . Procedure .If a resident admits to the facility with an antibiotic ordered, the nurse should perform the following: a. Document the indication for the use of the antibiotic based on record review and assessments of the new admission (diagnosis, lab results, symptoms .) .c. If antibiotic is ordered BUT is not indicated then the nurse should communicate this to the physician/practitioner and also the Director of Nurses for appropriate follow up if needed . A facility protocol titled, Loeb's Minimum Criteria for Initiating Antibiotic Therapy documented, the following symptoms were required prior to the administration of antibiotics for a non-catheterized resident with a possible urinary tract infection. Either one of the following criteria: acute dysuria (painful urination) or a temperature greater than 100 degrees F (Fahrenheit) or and increase of 1.5 degrees F above baseline and at least one of the following new or worsening symptoms were required: urgency, suprapubic pain, urinary incontinence, frequency, gross hematuria, and/or costovertebral angle tenderness. 1. Resident #21 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 01/11/19, documented the resident was moderately impaired in skills for daily decision making. She required extensive assistance of one staff member with toileting and hygiene. She had a [MEDICAL CONDITION] and was frequently incontinent of bladder. A nurse's progress note, dated 06/14/18 at 7:18 p.m., documented, .called to room by CMA (certified medication aide) in a urgent manner .pt (patient) laying on the floor .CMA states that pts (patients) walker was laying next to her when she found pt on the floor .pt was bluish in color .Pt starts to make loud snoring sound .(emergency service transport) called .to pick pt up for transfer to hospital for further evaluation . A hospital physician's orders [REDACTED]. A nurse's progress note, dated 06/15/18, documented the resident returned to the nursing facility with a [DIAGNOSES REDACTED]. The resident returned with a physician's orders [REDACTED]. A temperature log, dated (MONTH) (YEAR), documented one temperature was obtained for the resident. The resident's temperature was measured at 97.9 degrees F on 06/15/19. There was no documentation of a fever at or above 100 degrees F or an increase in temperature above baseline of 1.5 degrees F or more. A Loeb's minimum criteria form, dated 06/15/19, documented the resident was evaluated for a suspected urinary tract infection. The form documented the resident had a fever over 100 degrees F or a 2.4 degree above baseline increase in temperature and new or worsening urinary frequency. On 03/04/19, the resident's clinical record and hospital records were reviewed. There was no documentation of a fever or increase in 1.5 degrees above baseline in the resident's temperature. There was no documentation of new or worsening urgency, frequency, suprapubic pain, hematuria, costovetebral angle tenderness, and/or urinary incontinence. At 12:19 p.m., the DON (director of nurses) was asked to review the Loeb's criteria completed for the antibiotic ordered and administered to the resident starting on 06/14/18. She was asked to review the resident's clinical record and hospital record for signs/symptoms which warranted the use of an antibiotic. She stated the form was completed incorrectly. She stated the resident did not have a fever. She stated the antibiotic did not meet criteria and was not warranted. 2. Resident #27 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 01/29/19, documented the resident was cognitively alert in skills for daily decision making. She required limited assistance of one staff member with toileting and personal hygiene. She was occasionally incontinent of bowel and bladder. A temperature log, dated (MONTH) 2019, documented the resident's temperature ranged from 97.9 degrees F to 98.8 degrees F on 02/13/19 and 02/19/19. There were no measurements of a temperature of 100.0 degrees F or above or an increase in 1.5 degrees F above baseline. A nurse's progress note, dated 02/16/19 at 11:48 a.m., documented the resident experienced a changed in her level of consciousness and respiratory status. The physician was contacted and orders were received to transfer the resident to the hospital emergency department for evaluation and treatment. A nurse's progress note, dated 02/16/19 at 3:30 p.m., documented the resident was admitted to the hospital with [REDACTED]. A hospital history and physical report, dated 02/16/19, documented the resident presented to the emergency department for altered mental status. The resident reportedly received two physician ordered pain medications and was found cyanotic and difficult to arouse. She was diagnosed with [REDACTED]. The plan identified the resident was to receive antibiotics for the urinary tract infection. A urinalysis, dated 02/16/19, documented the resident's urine was positive for three plus leukocytes, four plus bacteria, white blood cells, hyaline casts and negative for [MEDICATION NAME]. A urine culture was recommended. A urine culture and sensitivity report, dated 02/18/19, documented the resident's urine was positive for less than 100,000 cfu/ml (colony forming units per milliliter) of Escherichia Coli (a bacteria). A hospital physician's orders [REDACTED]. A hospital discharge record, dated 02/19/19, documented the resident was diagnosed with [REDACTED]. A nurse's progress note, dated 02/19/19 at 9:55 p.m., documented the resident was readmitted to the nursing facility from the hospital with a [DIAGNOSES REDACTED]. A MAR (medication administration record), dated (MONTH) 2019, documented the resident received Keflex as ordered by the physician on 02/19/19 through 02/24/19. A Loeb's minimum criteria form, dated 02/19/19, documented the resident was not receiving [MEDICATION NAME] antibiotic treatment. The type of infection reviewed was marked as other and not identified as a suspected urinary tract infection. The comments documented the resident was admitted from the hospital with a [DIAGNOSES REDACTED]. The form was completed by the DON. A Loeb's minimum criteria form, dated 02/20/19, documented the resident was not receiving [MEDICATION NAME] antibiotic treatment. The type of infection reviewed was marked as other and not identified as a suspected urinary tract infection. The comments documented,[MEDICAL CONDITION] on ATB (antibiotic) upon return from the hospital. The form was completed by the ADON (assistant director of nurses). Both Loeb's minimum criteria forms documented a score of 15 or above was required for the administration of antibiotics. The scores for both forms was zero. A laboratory record, dated 02/20/19, documented, Dx (diagnosis) [MEDICAL CONDITION] s (without) septic shock, UTI, returned from hospital on [DATE]. On 03/04/19 at 11:46 a.m., the ADON stated the resident returned from the hospital with physician's orders [REDACTED]. She said, Usually we go with what the hospital documents and they [MEDICAL CONDITION] from respiratory. She was shown documentation from the hospital which documented the resident was prescribed an antibiotic for a urinary tract infection and not for any type of respiratory infection. She acknowledged the documentation showed the antibiotic was ordered for a UTI. She was then asked to review both Loeb's criteria completed when the resident returned from the hospital. She was asked why they were completed as other type of infection instead of for her [DIAGNOSES REDACTED]. At 11:55 a.m., LPN #1/infection control nurse stated when a resident returns from the hospital with orders for an antibiotic the facility usually just continues the antibiotic. She stated her role at the facility was to track and trend infections and antibiotic usage and ensure the antibiotic stewardship protocol was followed. At 12:31 p.m., the DON stated the resident was sent to the emergency room for a decreased level of alertness. She stated the hospital did not conclude the resident had a respiratory infection. She stated the resident was diagnosed with [REDACTED]. She was asked if the resident exhibited any signs or symptoms of a urinary tract infection. She stated the documentation would be included in the hospital records. She stated the resident did not exhibit any signs or symptoms of a urinary tract infection at the nursing home facility. She then reviewed the Loeb's criteria assessment she completed on 02/19/19. She stated when residents return from the hospital the criteria was completed to determine if the antibiotic was warranted. She stated the criteria was completed wrong for the resident. She said, I put in a [DIAGNOSES REDACTED]. She further stated she checked other for the type of infection instead of a UTI. At 12:47 p.m., the DON stated she had just completed a Loeb's criteria for the resident for her return to the facility on [DATE]. She stated she reviewed the resident for a suspected UTI and found the resident did not meet criteria for the antibiotic she was prescribed and administered.