Every finding on record at Unger Park Post Acute

Based on observation, interview, and policy review the facility failed to ensure the kitchen was sanitary, failed to ensure food was labeled and dated when opened, and further failed to ensure the dishwasher was washing and rinsing per manufacturer guidelines. This had the potential to affect all residents who received food from the kitchen. The facility identified one (#72) resident who did not receive meals from the kitchen. The facility census was 67.Findings include:1. Observation during initial tour of the kitchen on 04/27/26 at 8:08 A.M. revealed a plastic tray containing clean pitchers had a brown-like substance on the tray. Three open, three shelve carts with wheels had crumbs and debris on the shelves which contained insulated plate lids, sleeves of plastic lids, sleeves of bowls, and sleeves of cups. Three trays of juice on the left side of the reach in refrigerator and three trays of juice on the right side of the reach in refrigerator were unlabeled and not dated. Observation of the walk in refrigerator revealed a plastic baggie of bologna with a freeze date of 03/03/26 with no thaw date or use by date. The bologna appeared to be slimy and light in color. Observation of the high temperature dishwasher in use revealed the wash temperature was 168 degrees Fahrenheit (F) and the rinse temp was 160 degrees F, 176 degrees F, 178 degrees F, 178 degrees F, and 178 degrees F when running five cycles.Interview on 04/27/26 at 8:15 A.M. with [NAME] #135 revealed the dishwasher had not been running yet this morning. [NAME] #135 verified the dishwasher was a high temperature machine and should rinse at 180 degrees F at a minimum. [NAME] #135 verified the above findings in the reach in refrigerator and stated they are normally prepped the night before. [NAME] #135 verified the carts and the tray with the brown substance. [NAME] #135 verified the bologna in the walk-in refrigerator did not have a thaw date or use by date and stated that the bologna always had that color. [NAME] #135 discarded the bologna.2. Review of dishwasher label revealed hot water sanitizing requires a 150 degrees F minimum wash temperature and 180 degrees F minimum rinse temperature.Review of the dishwasher temperature log for January 2026 revealed the wash temperature on 01/14 was 148 degrees F at lunch time, 148 degrees F at lunch on 01/15, 146 degrees F on 01/21 at breakfast, 130 degrees F on 01/22 at breakfast, 147 degrees F on 01/23 at breakfast, 140 degrees F on 01/27 at breakfast and supper, 144 degrees F on 01/28 at breakfast. On 01/24 and 01/29 there was no documentation of wash temperatures, and on 01/30 and 01/31 there was no documentation of supper wash temperatures. Review of the dishwasher temperature log for February 2026 revealed on 02/05 the wash temperature was 149 degrees F at supper. No wash temperatures were documented on 02/01 for supper, 02/02, 02/03, 02/07, and 02/08 for breakfast or lunch, 02/09 and 02/18 for supper, 02/25 for lunch, and 02/28 for lunch and supper.Review of the dishwasher temperature log for March 2026 revealed there were no documented wash temperatures on 03/24 at supper time. Review of the dishwasher temperature log for April 2026 revealed on 04/01 at breakfast the wash temperature was 144 degrees F, 142 degrees F on 04/03 at breakfast, 140 degrees F at lunch on 04/07, and 148 degrees F on 04/16 at breakfast. The temperature log was missing documentation of wash temperatures on 04/03, 04/12, 04/19, 04/24, 04/25, and 04/26 at supper, on 04/09 at lunch, and on 04/23 there was no documentation of wash temperatures for any meal. 3. Review of dishwasher temperature log for January 2026 revealed rinse temperatures of 128 degrees F at breakfast on 01/21, 130 degrees F on 01/23 at breakfast, 138 degrees F on 01/25 at breakfast, 140 degrees F on 01/26 at supper, and 130 degrees F on 01/27 at supper. The temperature log was missing rinse temperatures on 01/28 at breakfast, 01/24 at both breakfast and lunch, 01/29 for all meals, and 01/30 and 01/31 for supper.Review of dishwasher temperature log for February 2026 revealed rinse temperatures of 149 degrees F on 02/05 at supper, 170 degrees F on 02/06 at supper, 165 degrees F on 02/07 at supper, 168 degrees F on 02/08 at supper, 175 degrees F on 02/11 and 02/12 at supper, 178 degrees F on 02/16 at supper, 179 degrees F on 02/20 at supper, 178 degrees F on 02/21 at supper, 172 degrees F on 02/22 at supper, 178 degrees F on 02/25 at supper, and 179 degrees F on 02/26 at supper. The log was missing rinse temperatures on 02/01, 02/09, 02/18, and 02/27 at supper, 02/02, 02/03, 02/07 and 02/08 at breakfast and lunch, 02/24 at breakfast and on 02/28 for lunch and supper.Review of the dishwasher temperature log for March 2026 revealed rinse temperatures of 175 degrees F on 03/02 at supper, 178 degrees F at lunch and 175 degrees F at supper on 03/05, 173 degrees F on 03/07 at supper, 178 degrees F on 03/11 at supper, 179 degrees F on 03/12 at supper, 174 degrees F on 03/13 at supper, 176 degrees F on 03/14 at lunch, 178 degrees F on 03/17 at breakfast, lunch, and supper, 176 degrees F on 03/18 at breakfast, 174 degrees F at breakfast and 178 F at supper on 03/19, 179 degrees F on 03/22 at supper, 178 degrees F on 03/26 at lunch and supper, 176 degrees F on 03/27 at lunch, 178 degrees F on 03/28 and 03/30 at supper, and 178 degrees F on 03/31 at lunch. The temperature log contained no rinse temperature at supper time on 03/24. Review of the dishwasher temperature log for April 2026 revealed rinse temperatures of 176 degrees F on 04/03 at breakfast, 178 degrees F on 04/04 at breakfast, lunch, and supper, 178 degrees F on 04/05 at breakfast, 178 degrees F on 04/08 at supper, 178 degrees F on 04/18 at breakfast and lunch, 176 degrees F at breakfast and 178 degrees F at lunch on 04/19, 170 degrees F on 04/20 at breakfast, 172 degrees F on 04/21 at supper, 178 degrees F at lunch and 168 degrees F at supper on 04/22, and 178 degrees F on 04/27 at breakfast. There was no rinse temperatures documented on the temperature log on 04/03, 04/12, 04/19, 04/24 and 04/26 for supper, 04/09 for lunch, and for any meal on 04/23. Interview on 04/29/26 at approximately 2:25 P.M. with [NAME] #135 verified the temperature logs had missing temperatures. [NAME] #135 also verified that there were dishwasher wash and rinse temperatures recorded under the minimum requirements for sanitizing. Review of policy titled Sanitation, revised November 2022 revealed dishwashing machines are operated according to manufacturer's instructions. General recommendations for heat and chemical sanitization are high-temperature dishwasher wash temperatures between 150 and 165 degrees F, and a rinse temperature of at least 180 degrees F.Review of the undated policy titled Kitchen Infection Control Policy, revealed dishwashing must meet temperature and sanitation standards.Review of undated policy titled Food Receiving and Storage, revealed refrigerated foods are labeled, dated, and monitored so they are used by their use-by date, frozen, or discarded. All foods stored in the refrigerator or freezer are covered, labeled and dated with a use-by date.This deficiency represents noncompliance investigated under Complaint Number 2645697.

Based on observation, staff interview, and policy review, the facility failed to ensure the facility was maintained in a safe, clean, comfortable homelike environment. This affected two residents (#46 and #56) and had the potential to affect all residents. The facility census was 67.Findings include:Observation on 04/29/26 at 10:40 A.M. of Resident's #46 and #56's bedroom revealed wallpaper to be peeling from the wall in multiple areas including behind the each of the resident's headboards, below the window, and near the baseboards. There was also a black substance noted to be around the base of the toilet in the bathroom.Interview on 04/29/26 at 10:45 A.M. with Certified Nursing Assistant (CNA) #175 verified the peeling wallpaper in Resident's #46 and #56's bedroom as well as the black substance around the base of the toilet. Furthermore, concurrent observation and interview with CNA #175 verified in the C hall restroom, the three light covers were cracked/broken.Review of the facility policy titled Homelike Environment with a revision date of February 2021 revealed residents are provided with a safe, clean, comfortable and homelike environment.This deficiency represents non-compliance investigated under Complaint Number 2645697.

Based on observation, review of the medical record, staff interview, and policy review, the facility failed to ensure staff wore personal protective equipment during high contact resident care for residents requiring enhanced barrier precautions. This affected three (#23, #72, #75) of four residents reviewed for enhanced barrier precautions and had the potential to affect nine residents (#4, #9, #11, #14, #18, #23, #28, #72, and #75) on enhanced barrier precautions. Additionally, the facility failed to ensure hand hygiene during wound care was completed. This affected one (#28) of one resident reviewed for wound care. The facility identified five residents requiring wound care. The facility census was 67. Findings include:1. Review of the medical record for Resident #23 revealed an admission date of 12/21/24. Diagnoses included atrial fibrillation, hypertension, chronic kidney disease, neuromuscular dysfunction of the bladder, and urinary retention. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition. The resident had an indwelling catheter, and the resident required substantial/maximal assistance of staff for toileting hygiene. Review of a physician order dated 01/10/25 revealed an order for enhanced barrier precautions and for staff to use gown and gloves for high-contact resident care including dressing, bathing, showering, transfers, hygiene care, changing linens, changing briefs, assisting with toileting, dressing changes, and care of any device (tracheostomy, central line, tube feeding, catheter.) Review of the plan of care last revised 03/20/26 revealed the resident was on enhanced barrier precautions during high-contact resident care activities due to the presence of indwelling urinary catheter device. Interventions included for staff to wear gloves and gown for hands on care and utilize personal protective equipment during high-contact resident care activities including brief changes and device care. Observation on 04/28/26 at 9:55 A.M. of catheter care for Resident #23 with Certified Nursing Assistant (CNA) #167 revealed CNA #167 wore gloves but was not wearing a gown while providing catheter care. Further observation revealed there was an enhanced barrier precaution sign on the resident's door stating to wear a gown during high-contact care. Interview on 04/28/26 at 9:55 A.M., CNA #167 verified the resident was on enhanced barrier precautions. CNA #167 verified she did not wear a gown while providing catheter care for the resident. Interview on 04/29/26 at 7:15 A.M., the Director of Nursing (DON) verified staff should be wearing a gown while providing catheter care. 2. Review of the medical record for Resident #72 revealed an admission date of 04/22/26. Diagnoses included cerebral palsy, epilepsy, depression and protein-calorie malnutrition. Review of a physician order dated 04/22/26 revealed an enteral feed order for Osmolite 1.5 continuous 28 milliliters/hour for 20 hours via peg tube. Review of a physician order dated 04/27/26 revealed an order for staff to use a gown and gloves for high-contact resident care including bathing, showering, transfers, hygiene care, changing linens, changing briefs, assisting with toileting, dressing changes, and care of any device (tracheostomy, central line, tube feeding, catheter). Review of the admission MDS dated [DATE] revealed the assessment was in progress and the resident had severe cognitive impairment. The resident was receiving enteral nutrition. Observation on 04/28/26 at 11:21 A.M. revealed the resident had an enhanced barrier precaution sign posted on the room door. Further observation revealed CNA #109 and CNA #112 were providing incontinence care for the resident. CNA #109 and CNA #112 wore gloves but were not wearing gowns. Interview on 04/28/26 at 11:21 A.M., CNA #109 and CNA #112 verified the resident was on enhanced barrier precautions and they were not wearing gowns while providing incontinence care. Interview on 04/29/26 at 7:15 A.M., the DON verified staff should wear a gown while providing incontinence care for a resident on enhanced barrier precautions. 3. Review of the medical record for Resident #28 revealed an admission date of 06/13/25. Diagnoses included dementia, depressive disorder, type two diabetes mellitus, anxiety, and dysphagia. Review of the quarterly MDS dated [DATE] revealed the resident had impaired cognition. The resident was dependent on staff for bed mobility, toileting, and transfers. Review of a wound nurse practitioner progress note dated 04/22/26 revealed the resident had a diabetic ulcer to the left heel measuring one centimeter (cm) in length, one cm in width, with an undetermined depth. The wound was 100 percent scabbed and crusted with no exudate and described as dry and callused with no signs of infection. Observation on 04/28/26 at 2:40 P.M. of wound care for the resident with Registered Nurse (RN) #155 revealed the nurse removed the soiled wound dressing and cleansed the wound. RN #155 then removed her gloves and applied new gloves without performing hand hygiene after removing the soiled gloves. Interview on 04/28/26 at 2:43 P.M., RN #155 verified not completing hand hygiene after removing the soiled gloves and donning new gloves. Interview on 04/29/26 at 7:15 A.M., the DON verified nurses should perform hand hygiene between glove changes. Review of the facility policy Handwashing/Hand Hygiene revealed hand hygiene would be completed before moving from work on a soiled body site to a clean body site on the same resident and immediately after glove removal. 4. Review of the medical record for Resident #75 revealed the resident was admitted on [DATE] and had diagnoses including chronic obstructive pulmonary disease, morbid obesity, and calculus of kidney. Review of Resident #75's MDS assessment dated [DATE] revealed the resident was cognitively intact. Medical record review for Resident #75 indicated that the resident had orders for enhanced barrier precautions including the use of gown and gloves for high contact resident care due to the resident having a peripherally inserted central catheter (PICC) line. Review of Resident #75's Medication Administration indicated that the resident received an antibiotic, Ertapenem 1 gram, intravenously daily for a urinary tract infection between 4/23/26 and 4/29/26 Observation of Resident #75 was conducted between 07:02 A.M. and 07:29 A.M. on 4/29/26. Licensed Practical Nurse (LPN) #174 administered Ertapenem to Resident #75 during this time. Ertapenem was supplied via an elastomeric pump and infused via Resident #75's PICC line. LPN #174 wore gloves but did not wear a gown during administration of Ertapenem when accessing and using Resident #75's PICC line. Interview with LPN # 174 at 7:29 A.M. on 4/29/26 confirmed that a gown was not worn during antibiotic administration, access and use of the Resident 75's PICC line. Review of facility policy titled Enhanced Barrier Precautions Policy states that residents eligible for enhanced barrier precautions (EBP) include those with indwelling medical devices. The policy states that EBP involves the use of gown and gloves for high contact resident care activities including (Indwelling) device care or use.

Based on review of the medical record, review of the beneficiary notification documentation, staff interview, and policy review, the facility failed to ensure residents were provided the required Notice of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN). This affected four (#2, #41, #76, and #77) of four residents reviewed for required beneficiary notices. The facility census was 67.Findings include:1. Review of Resident #2's medical record revealed an admission date of 02/16/26. Diagnoses included chronic obstructive pulmonary disease (COPD), bipolar disorder, rheumatoid arthritis, muscle wasting and atrophy, and acute respiratory failure with hypoxia.Review of Resident #2's Medicare five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had intact cognition with a Brief Interview for Mental Status (BIMS) score of 15.Review of Resident #2's Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review document revealed Resident #2's Medicare part A skilled services episode start date was 02/26/26 and the last covered day of part A service was 04/10/26. Furthermore, due to a facility oversight, the SNF ABN and NOMNC were not provided to Resident #2.2. Review of Resident #41's medical record revealed an admission date of 02/21/26 and a discharge date of 04/22/26. Diagnoses included generalized osteoarthritis, immunodeficiency, anxiety, severe protein-calorie malnutrition, and adult failure to thrive.Review of Resident #41's admission/Medicare five-day MDS assessment dated [DATE] revealed Resident #41 had intact cognition with a BIMS score of 15.Review of Resident #41's SNF Beneficiary Protection Notification Review document revealed Resident #41's Medicare part A skilled services episode start date was 02/21/26 and the last covered day of part A service was 04/22/26. Furthermore, due to a facility oversight, the SNF ABN and NOMNC were not provided to Resident #41.3. Review of Resident #76's medical record revealed an admission date of 01/29/26 and a discharge date of 03/20/26. Diagnoses included generalized osteoarthritis, pulmonary fibrosis, muscle wasting and atrophy, thrombocytopenia, and chronic kidney disease.Review of Resident #76's admission/Medicare five-day MDS assessment dated [DATE] revealed Resident #2 had intact cognition with a BIMS score of 15.Review of Resident #76's SNF Beneficiary Protection Notification Review document revealed Resident #76's Medicare part A skilled services episode start date was 01/29/26 and the last covered day of part A service was 03/20/26. Furthermore, due to a facility oversight, the SNF ABN and NOMNC were not provided to Resident #76.4. Review of Resident #77's medical record revealed an admission date of 02/06/26 and a discharge date of 03/25/26. Diagnoses included COPD, mild protein-calorie malnutrition, anemia, muscle weakness, bipolar disorder, and hyperlipidemia.Review of Resident #77's admission/Medicare five-day MDS assessment dated [DATE] revealed Resident #77 had intact cognition with a BIMS score of 13.Review of Resident #77's SNF Beneficiary Protection Notification Review document revealed Resident #77's Medicare part A skilled services episode start date was 02/06/26 and the last covered day of part A service was 03/25/26. Furthermore, due to a facility oversight, the SNF ABN and NOMNC were not provided to Resident #77.Interview on 04/28/26 at 4:38 P.M. with Regional MDS Nurse #190 verified social services was not aware they were required to provide beneficiary notification including the SNF ABN and NOMNC to residents. Regional MDS Nurse #190 stated Residents #2, #41, #76, and #77 all should have been provided with the SNF ABN and NOMNC but were not due to the facility oversight.Review of the facility policy titled NOMNC/ABN Notice - Social Services Procedures dated June 2018 revealed a Medicare provider or health plan must deliver a completed copy of the NOMNC to beneficiaries/enrollees receiving covered skilled nursing services. The NOMNC must be delivered at least two calendar days before Medicare covered services end. The NOMNC should be delivered at minimum three calendar days to allow adequate time for appeals.

Based on medical record review, interview, and facility policy review, the facility failed to ensure adequate adverse effect monitoring for a resident using psychotropic medications. This affected one (#26) of five residents reviewed for unnecessary and psychotropic medications. The facility census was 67.Findings include:Review of the medical record for Resident #26 revealed an admission date of 04/08/26, diagnoses included morbid obesity, type II diabetes, and fracture of left femur. Review of Resident #10's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #26 was cognitively intact.Review of the medical record for Resident #26 found current physician orders for the administration of two psychotropic medications. One order dated 04/08/26 was for buspirone (an antianxiety agent) 5 milligrams (mg) two times a day for anxiety. Another order dated 04/09/26 was for duloxetine (an antidepressant) 60 mg at bedtime for depression. Resident #26 was also had an ordered dated 04/08/26 for behavior monitoring (0 - none, 1 - afraid, 2 - agitated, 3 - angry, 4 - anxious, 5 - mood change, 6 - noisy, 7 - restless, 8 - withdrawn/depressed, 9 - crying, 10 - combative) each shift and an order dated 04/08/26 and discontinued on 04/09/26 at 4:26 P.M. for psychotropic drug adverse effects of dry mouth, constipation, blurred vision, disorientation, confusion, drowsiness, slurred speech, dizziness, restlessness, muscle tremor, agitation, headache, rash photosensitivity, increased falls, increase in behavior, nausea/vomiting, disturbed gait, and involuntary movement.Review of Resident #26's Medication Administration Record (MAR) revealed that Resident # 26 had received buspirone and duloxetine as ordered between 4/10/26 and 4/28/26. Further review of Resident #26's MAR revealed the resident experienced no behaviors and had no documented adverse reactions to the medications on the night shift of 04/08/26 and the day shift of 04/09/26. Interview with Director of Nursing (DON) #128 at 11:53 A.M. on 04/30/26 confirmed that psychotropic adverse effect monitoring was discontinued on 04/09/26 and there was no current order for adverse effect monitoring at the time of the interview. DON #128 also confirmed Resident #26 was not experiencing any behaviors. Review of the facility policy titled Psychoactive/Psychotropic Medication Use, dated 04/25 stated psychotropic medication is any drug that affects the brains activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: antipsychotic, antidepressant, antianxiety, mood stabilizer, and sedative-hypnotic. A resident will only receive psychotropic medications when necessary to treat a specifically diagnosed condition that is documented in the medical record and the resident receiving a psychotropic medication will be monitored for medication effectiveness, behavioral symptoms, and potential adverse events.

Based on review of the medical record, staff interview, and policy review, the facility failed to ensure care plans were timely initiated and revised for new wounds. This affected one (#28) of one resident reviewed for wound care. The facility identified five residents with wounds. The facility census was 67. Findings include:Review of the medical record for Resident #28 revealed an admission date of 06/13/25. Diagnoses included dementia, depressive disorder, type two diabetes mellitus, anxiety, and dysphagia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition. The resident was dependent on staff for bed mobility, toileting, and transfers. Review of a wound nurse practitioner progress note dated 04/22/26 revealed the resident had a diabetic ulcer to the left heel measuring one centimeter (cm) in length, one cm in width, with an undetermined depth. The wound was 100 percent scabbed and crusted with no exudate and described as dry and callused with no signs of infection. Further review of the medical record revealed the wound was present since 01/02/26.Review of Resident #28's plan of care revealed there was no care plan with interventions in place for the diabetic ulcer to the left heel.Interview on 04/28/26 at 3:50 P.M., MDS Registered Nurse (MDSRN) #138 verified a care plan should have been initiated for the resident's diabetic ulcer. MDSRN #138 was not sure if the wound care nurse or herself was responsible to ensure wound care plans were in place. Interview on 04/29/26 at 7:15 A.M., the Director of Nursing (DON) verified the MDS nurse was responsible for ensuring wound care plans were initiated. Review of the facility policy Care Plans, Comprehensive Person-Centered, revised 03/2022, revealed assessments of residents were ongoing and care plans were revised as information about the residents and the residents' conditions change.

Based on observation, record review, interview, and policy review, the facility failed to ensure female residents were shaved. This affected one (#75) of one resident reviewed for shaving. The facility also failed to ensure residents in the dining room were fed in a dignified manner. This affected one (#45) of one resident observed for feeding. The facility identified seven residents (#6, #12, #27, #45, #60, #66, and #74) who required assistance with feeding. The facility census was 67.Findings include:1. Review of medical record for Resident #75 revealed an admission date of 08/17/25 with diagnoses including but not limited to paranoid schizophrenia, depression, anxiety, and the need for assistance with personal care.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Resident #75 required partial/moderate assistance for bathing/showering and setup or clean-up assistance for personal hygiene.Review of shower documentation for 04/24/26 and 04/28/26 revealed the resident received a bed bath for both days and no shaving was documented.Observation on 04/27/26 at 9:39 A.M. of Resident #75 revealed long white hairs on the resident's chin.Observation 04/28/26 at 10:47 A.M. revealed Resident #75 sitting out in the hall by the nurse's station and the long white hairs remained on the resident's chin.Observation and interview on 04/29/26 at 9:26 A.M. of Resident #75 revealed the long white hairs remained on the resident's chin. Resident #75 stated that she will shave her chin sometimes and stated that the staff do not shave it for her. Resident #75 stated the staff do not offer to shave the hairs on her chin.Interview on 04/29/26 at 2:36 P.M. with Certified Nursing Assistant (CNA #177) revealed they would shave female residents on their shower days. CNA #177 stated that Resident #75 would allow the staff to shave her chin. CNA #177 verified Resident #75 had long white hairs on her chin and would shave them if the resident liked.Further observation on 04/30/26 at 8:24 A.M. revealed Resident #75 chin was shaved.Review of policy titled Dignity revised February 2021 revealed when assisting with care, residents are supported in exercising their rights. For example, residents are groomed as they wish to be groomed (hair styles, nails, facial hair, etc.).2. Review of medical record for Resident #45 revealed an admission date of 08/17/23 with diagnoses including but not limited to Alzheimer's disease with early onset, dementia with agitation, and need for assistance with personal care.Review of MDS dated [DATE] revealed Resident #45 had severely impaired vision and was dependent for eating.Review of physician orders revealed Resident #45 required assistance with feeding.Observation on 04/27/26 at 11:48 A.M. of CNA #112 revealed the CNA stood beside the resident to assist the resident with eating for the entire meal. Interview on 04/27/26 at 12:03 P.M. with CNA #112 revealed that she normally sits down to assist residents with meals. CNA #112 verified she stood beside the resident to assist with the meal. CNA #112 stated the resident was blind so the staff can hand the resident finger foods but have to physically assist with the rest of the meal.Further review of policy titled Dignity revised February 2021 revealed when assisting with care, residents are supported in exercising their rights. For example, residents are provided with a dignified dining experience.This deficiency represents non-compliance investigated under Master Complaint Number 2976687 and Complaint Number 2645697.

Based on interview, medical record review, and facility policy review, the facility failed to obtain informed consent before treatment with psychotropic medications. This affected one (#26) of five residents reviewed for psychotropic medications and has the potential to affect 31 (#2, #5, #7, #12, #13, #14, #17, #19, #20, #21, #22, #23, #32, #33, #34, #35, #39, #40, #42, #43, #45, #46, #47, #49, #51, #55, #56, #59, #60, #62, and #75) residents that the facility identified as receiving psychotropic medications. The facility census was 67.Findings include:Review of the medical record revealed Resident #26 was admitted [DATE] and had diagnoses that included morbid obesity, type II diabetes mellitus, and a fracture of left femur. Review of Resident #26's Minimum Data Set (MDS) 3.0 assessment submitted 4/15/26 revealed Resident #26 was cognitively intact.Review of the medical record for Resident #26 found active physician orders for the administration of two psychotropic medications. One order dated 04/08/26 was for buspirone (an antianxiety agent) 5 milligrams (mg) two times a day for anxiety. Another order dated 04/09/26 was for duloxetine (an antidepressant) 60 mg at bedtime for depression. Review of Resident #26's Medication Administration Record (MAR) revealed that Resident # 26 had received these medications as ordered between 4/10/26 and 4/28/26. Further review of the medical record for Resident #26 found a Psychotropic Medication Administration Disclosure form signed by Resident #26 on 4/29/26 and by Registered Nurse (RN) #133 as the clinician performing review of the form with Resident #26.Interview with RN #133 on 4/30/26 at 2:35 P.M. confirmed that there was no Psychotropic Medication Administration Disclosure performed at admission or prior to the administration of psychotropic medications for Resident #26.Review of the facility policy titled Psychoactive/Psychotropic Medication Use, dated 04/25 states that prior to administration of a psychotropic medication, the prescribing clinician will obtain informed consent from the resident and document in the medical record.

Based on observation, review of the medical record, staff interview, review of the Resident Council meeting minutes, review of the concern/grievance log, and policy review, the facility failed to ensure timely response and follow-up of resident concerns. This affected one (#3) of two residents reviewed for personal property. The facility census was 67.Findings include:Review of the medical record for Resident #3 revealed an admission date of 11/19/18. Diagnoses included type two diabetes mellitus, paranoid schizophrenia, bipolar disorder, and chronic obstructive pulmonary disease.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. Review of the Resident Council meeting minutes dated 01/26/26, 02/25/26, 03/26/26, and 04/26/26 revealed no documentation of Resident #3 reporting missing clothing items. Resident #3 was documented as present at the Resident Council meeting on 02/25/26.Review of the grievance/concern log dated 01/01/26 through 04/26/26 revealed no documentation of missing clothing items for Resident #3. Interview on 04/27/26 at 10:59 A.M., Resident #3 revealed she had been missing a clothing undergarment and provided a description of the missing item. Resident #3 revealed the item had been missing for a few months. Resident #3 revealed she had reported the missing item many times to staff and had reported the missing item at a Resident Council meeting. Resident #3 revealed no one had followed up with her regarding the missing item. Interview on 04/28/26 at 11:17 A.M., Social Worker (SW) #183 revealed staff should fill out a grievance form for reported missing items. SW #183 revealed no staff had notified her of any missing clothing items for Resident #3Interview on 04/29/26 at 7:54 A.M., the Activity Director (AD) #115 revealed the resident had voiced a concern of the missing undergarment at a Resident Council meeting held on 02/25/26. AD #115 revealed she had not documented the concern in the meeting minutes because the former Administrator had told her what items to document in the meeting minutes. AD #115 revealed the Administrator was aware of Resident #3's report of the missing undergarment. Interview on 04/29/26 at 8:37 A.M., the Director of Nursing (DON) revealed the former Administrator was going to follow up with the resident's family regarding the missing clothing item. The DON revealed social services should be notified regarding resident concerns. The DON revealed there was no documentation in the medical record or on the grievance/concern log of any follow up on the resident's missing clothing item concern. Interview on 04/20/26 at 7:57 A.M., Laundry Staff (LS) #170 revealed she had worked in the facility laundry for over one year. LS #170 revealed the facility laundered the resident's clothing. LS #170 revealed the resident's clothing was washed separately from other resident clothing as the resident required a special laundry detergent. LS #170 revealed staff had not notified her about a missing undergarment for the resident. LS #170 revealed staff should have reported the missing clothing item to her, and she would have looked for the missing item. Observation on 04/20/26 at 8:05 A.M., with LS #170 revealed a basket containing two unlabeled undergarments in the laundry room. LS #170 was provided with a description of the missing clothing undergarment by the surveyor. LS #170 then went to the resident's room with the two unlabeled undergarments. Resident #3 verified one of the undergarments was the one she had been missing since February. LS #170 revealed she would relabel the item for the resident. Review of the facility policy Grievances/Complaints, Filing dated 2001, revealed residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances. Further review of the policy revealed all grievances, complaints or recommendations stemming from resident or family groups concerns issues of resident care in the facility would be considered and actions on such issues would be responded to in writing, including a rationale for the response.

Based on observation, resident interview, staff interview, and facility policy review, the facility failed to ensure a homelike environment by failing to ensure the dining room ceiling was intact and without holes. This affected one (#28) of five residents reviewed for environment. The facility also failed to ensure a homelike dining experience for the 14 (#2, #3, #5, #14, #16, #17, #20, #28, #43, #45, #52, #53, #56, and #59) residents who routinely ate meals in the dining room and further failed to provide comfortable and well-fitting bed linens for Resident #10. The facility census was 67.Findings include:1. Review of the medical record for Resident #28 revealed an admission date of 06/13/25. Diagnoses included dementia, congestive heart failure and type 2 diabetes. Review of Resident #28's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 had moderate cognitive impairment. Observation of the dining room ceiling occurred about 3:10 P.M. on 4/28/26. A missing tile in the drop ceiling created a rectangular hole. The hole exposed a visible blue wire. Observation of the dining room ceiling occurred at 10:17 A.M. on 4/29/26. The rectangular hole in the ceiling was still present with visible wires. Resident #28 was sitting in the dining room and interviewed at 10:19 A.M. on 4/29/26. Resident #28 acknowledged the hole in the ceiling and stated she was worried about the ceiling falling and people getting hurt. Interview conducted with [NAME] #135 at 10:21 A.M. on 4/29/26 confirmed the hole in the dining room ceiling. [NAME] #135 could not say for how long the hole in the ceiling had been there but added that maintenance had doing some work above the ceiling. Observation of the dining room ceiling took place at 12:11 P.M. on 4/29/26. Three residents were sitting below the hole eating lunch. Observation of the dining room ceiling occurred at 7:54 A.M. on 4/30/26. The rectangular hole in the ceiling was still present. Review of the facility policy titled Homelike Environment, revised 02/2021 states the facility will provide residents with a safe, clean, comfortable and homelike environment. 2. Observation on 04/27/26 from 11:21 A.M. until 11:48 A.M. of the dining room revealed the first tray of food was delivered to one resident at a three top table at 11:21 A.M. The meal was sat on front of the resident and was left on the tray. At 11:23 A.M. staff were then observed to serving a tray to another resident at another three top table. Staff continued to serve meals in a random order, all meals were left on the trays. At 11:31 A.M. the second resident at the first three top table received a meal tray. At 11:33 A.M. the third resident from the first three top table received their meal tray. The last of three residents at the second table received their tray at 11:39 A.M. During the observation of the meal service a resident from a middle three top table was observed to turn her wheelchair away from the table where two residents were eating and the resident reached and grabbed a hamburger off of another resident's tray that was just sitting there uncovered and in front of a resident waiting on staff to assist with feeding. Staff were observed intervening, turning the resident back to her table and providing her with a tray of food. At 11:40 A.M. staff were observed taking the plate with touched hamburger back to the kitchen, obtained another and returned at 11:42 A.M. with a tray containing a covered plate. At 11:48 A.M. a CNA came into the dining room to assist the resident with eating her meal. Interview on 04/27/26 at 11:42 A.M. with Business Office Manager (BOM #122) revealed that the facility did not normally take the plates off the trays. BOM #122 verified the plates, drinks, and silverware were not taken off the trays when the food was delivered. BOM #122 verified the table were not served together and they should have been. Interview on 04/29/26 at approximately 10:58 A.M. with Dietary Director (DD #125) revealed that the staff serving in the dining room should take the plates and drinks off the trays when they are delivered. DD #125 verified the tables should be served together. 3. Review of the medical record for Resident #10 revealed an admission date of 04/16/26. Diagnoses included cerebral infarction due to occlusion or stenosis of small artery, type II diabetes, and cognitive communication deficit. Review of Resident #10's MDS assessment dated [DATE] indicated Resident #10 had moderate cognitive impairment. Observation of Resident #10 lying in bed occurred at 8:57 A.M. on 4/27/26. Bed sheets were not covering the entire pressure mattress. Interview with a Resident #10's Representative occurred at 10:23 A.M. on 04/27/26 in Resident #10's room. The Resident Representative stated that sheets tend to slide off the mattress. Observation of Resident #10 lying in bed occurred at 8:19 A.M. on 04/30/26. The bed sheet was not covering the entire mattress, the corner of the bed on the Resident's left hand side by the Resident's head had mattress exposed. Interview with Resident #10 at 8:19 A.M. on 04/30/26 revealed the sheets are bothersome and do not fit right. Resident #10 confirmed that the issue has been brought to the attention of facility staff, but nothing has been done. Interview with Maintenance Director (MD) #113 occurred at 8:32 A.M. on 4/30/26. MD #113 confirmed that the bed sheet was not covering Resident #10's mattress and this was a problem with pressure mattress that Resident #10 used. Review of the facility policy titled Homelike Environment, revised 02/2021 states that the facility will provide a comfortable and homelike environment for residents including clean bed linens that are in good condition. This deficiency represents non-compliance investigated under Master Complaint Number 2976687 and Complaint Number 2645697.

Based on record review, resident interview, staff interview, and policy review the facility failed to ensure a procedure was in place to determine which residents required ancillary services. This affected one (#51) of one resident reviewed for dental services. The facility census was 67.Findings include:Review of Resident #51's medical record revealed an admission date of 12/04/25. Diagnoses included muscle wasting and atrophy, type two diabetes mellitus, osteoarthritis, gastro-esophageal reflux disease without esophagitis, and ataxia. Review of Resident #51's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #51 had intact cognition with a Brief Interview for Mental Status (BIMS) score of 15. Furthermore, Resident #51 did not have dental pain. Review of Resident #51's care plan dated 02/08/26 revealed Resident #51 was at risk for difficulty chewing related to broken teeth with interventions that included dental consultation and follow-up as indicated and to notify the physician of symptoms of dental infections or complications such as swollen gums, pain, tooth sensitivity, cavities, mouth sores, or fever. Review of Resident #51's physician orders revealed an order with a start date of 02/01/26 that read may be seen by dentist, podiatrist, audiologist, or optometrist per facility protocol. Interview on 04/27/26 at 9:46 A.M. with Resident #51 revealed Resident #51 had damaged teeth. Resident #51 stated she had dental pain and would tell nurses and aides about her dental pain and no one had done anything about it. Resident #51 stated no one from the facility had asked her if she needed dental services.Interview on 04/29/26 at 8:43 A.M. with Social Service Representative #183 verified Certified Nurse Aide (CNA) #110 handled the ancillary services and scheduling the residents for dental and vision clinics.Interview on 04/29/26 at 9:01 A.M. with CNA #110 revealed when a resident is admitted to the facility, she will ask them if they want seen by vision, dental, and hearing services. If the resident accepts, they will be added to the appropriate list to be seen. If the resident declines any ancillary services, they are not scheduled for the services. If a resident were to require services after declining upon admission, they would be added to the list to be seen, or the facility would schedule them for an emergency visit. CNA #110 verified there was no documentation regarding residents accepting or declining ancillary services.Interview on 04/29/26 at 9:13 A.M. with Marketing Director #103 verified upon admission, residents will sign the admission packet which included the ancillary services that were provided at the facility. Furthermore, Marketing Director #103 verified she was not aware of any documentation regarding residents accepting or declining ancillary services.Review of the list of residents to be seen at dental clinic revealed Resident #51 was not on the dental clinic list.Review of the facility policy titled Dental Services with a revision date of December 2016 revealed social services representatives will assist residents with appointments, transportation arrangements, and for reimbursement of dental services under the state plan, if eligible.

Based on record review, interview, and policy review the facility failed to ensure bed hold notices and transfer notices were given to residents. This affected one (#68) of one resident reviewed for bed hold notices and transfer notices. The facility census was 67.Findings include:Review of medical record for Resident #68 revealed an admission date of 08/17/26 with diagnoses including but not limited to paranoid schizophrenia, depression, anxiety, hypertension, and cognitive communication deficit.Review of census lines revealed the resident went to the hospital from [DATE] to 08/17/25, 08/25/25 to 08/26/25, 01/13/26 to 01/20/26, and 04/10/26 to 04/22/26.Review of bed hold notices dated 08/15/25 and 08/25/25 revealed the resident signed both forms on the day sent to the hospital.Review of bed notices dated 01/13/26 and 04/10/26 revealed the forms were not signed and there was blank certified mail labels stapled to the forms.No transfer notices could be located by the facility for any of the hospitalizations.Interview on 04/29/26 at 2:50 P.M. with Business Office Manager (BOM #122) revealed that the certified mail labels did not contain a date or name and address as to where the forms were sent. BOM #122 verified there was no way of knowing when or where the notices were sent by looking at the certified mail notice stapled to the form. BOM #122 verified that Resident #68 signed her own bed hold notice forms on 08/15/25 and 08/25/25.Interview on 04/29/26 at 3:53 P.M. with Regional MDS revealed that no transfer notices were sent for any of Resident #68 hospitalizations.Review of policy titled Bed Holds and Returns revised on October 2022 revealed all residents/representatives are provided written information regarding the facility and state bed hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). Residents, regardless of payor source, are provided written notice about these policies at least twice: well in advance of any transfer (ex: in the admission packet) and at the time of transfer or if the transfer was an emergency within 24 hours.Review of policy titled Transfer or Discharge Notices not dated revealed a notice of transfer is provided to the resident and representatives as soon as practicable before the transfer and to the long term care (LTC) ombudsman when practicable (e.g., in a monthly list of residents that includes all notice content requirements). Notice of facility bed-hold and return policies are provided to the resident and representative within 24 hours of emergency transfer.

Based on staff interview, review of employee files, review of the Bureau of Criminal Investigation (BCI) log and review of the facility policy, the facility failed to ensure employee background checks were completed prior to employment. This had the potential to affect all 56 residents residing in the facility. The facility census was 56.Findings include:Review of Dietary Aide (DA) #238's employee file revealed a start date of 02/16/25. Further review revealed no evidence a BCI check was completed for DA #238.Review of the facility's BCI log revealed DA #238 was not logged as having a background check completed. Interview on 07/15/25 at 1:28 P.M. with Human Resource Director (HRD) #253 verified DA #238 did not have a background check completed. Review of the facility policy titled, Background Screening Investigations, revised March 2019, revealed the facility conducted employment background screening checks, reference checks, and criminal conviction investigation checks on all applicants for positions with direct access to residents. Direct access employee meant any individual who had access to a resident or patient of a long term care facility or provider through employment or through a contract that had duties that involved, or may involve, one-on-one contact with a patient or resident of the facility or provider. The director of personnel, or designee, conducted background checks, reference checks, and criminal conviction checks (including fingerprinting) on all potential direct access employees and contractors. Background and criminal checks were initiated within two days of an offer of employment or contract agreement, and completed prior to employment.

Based on medical record reviews, staff interviews, review of the facility's infection control logs, review of facility in-services, and review of the facility's policy, the facility failed to prevent and respond to an increased pattern of urinary tract infections (UTIs). This affected two (#16 and #60) of two residents reviewed for UTIs. The facility census was 74. Findings include: Review of the medical record revealed Resident #16 was admitted to the facility on [DATE]. Diagnoses included type II diabetes mellitus, chronic obstructive pulmonary disease, shortness of breath, asthma, dysphagia, need for assistance with personal care, insomnia, hyperlipidemia, adult failure to thrive, osteoarthritis, infestation, low back pain, hypertension, anxiety, and bipolar disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], identified Resident #16 was cognitively intact. The resident was frequently incontinent of urine and occasionally incontinent of bowel. Review of the infection control logs dated 07/01/24 through 12/15/24, revealed Resident #16 was identified to have a UTI on 08/01/24, 09/05/24, 09/26/24, and 11/05/24. The urine cultures for the UTIs on 07/30/24, 09/02/24, 09/26/24 identified Escherichia coli (E. coli) in the resident's urine. All UTIs were monitored and treated. Review of the medical record revealed Resident #60 was admitted to the facility on [DATE]. Diagnoses included fibromyalgia, hypokalemia, hyperlipidemia, spinal stenosis, anxiety, upper abdominal pain, nausea with vomiting, gastro-esophageal reflux disease, diverticulitis of intestine, osteoporosis, osteoarthritis, chronic pain syndrome, unsteadiness on feet, muscle weakness, pain in right leg, pain in left leg, difficulty walking, and depression. Review of the quarterly MDS assessment dated [DATE], identified Resident #60 was cognitively intact. The resident was always continent of bladder and bowel. Review of the infection control logs dated 07/01/24 through 12/15/24, revealed Resident #60 was identified to have a UTI on 11/05/24 and 11/27/24. The urine cultures for the UTIs on 11/05/24 and 11/27/24 identified E. coli in the resident's urine. Review of the infection control logs from 07/01/24 through 12/15/24, revealed there were at least 58 residents diagnosed with UTIs which were not present upon admission. Review of the staff in-services dated 07/01/24 through 12/15/24, revealed no in-services pertaining to prevention of UTIs. One in-service regarding handwashing was completed on 10/09/24. An interview on 12/19/24 at 8:33 A.M. with Registered Nurse #229, who was identified as being the facility's infection preventionist, revealed when there was an increase in any type of infection, the facility should implement education by in servicing all applicable staff. RN #229 verified the facility had not recognized an increase in UTIs or E. coli. RN #229 stated the facility conducted the handwashing in-service on 10/09/24 related to another infection control concern and had not provided any other in-services related to an increase in UTIs or E. coli. Review of the facility policy titled Surveillance for Infections, not dated, revealed the Infection Preventionist (IP) would conduct ongoing surveillance for healthcare-associated infections and other epidemiologically significant infections that have substantial impact on potential resident outcome and that may require transmission-based precautions and other preventative interventions.

Based on observation, record review, staff interview, review of the activity calendar, and policy review the facility failed to ensure activities on memory care unit met the needs and preferences of the residents. This affected all 13 residents (#02, #04, #11, #13, #19, #24, #35, #40, #41, #46, #58, #174, and #175) on the memory care unit. The facility census was 74. Findings include: Review of medical record for Resident #04, revealed an admitted [DATE] with diagnoses including but not limited to Alzheimer's disease with late onset, dementia with other behavioral disturbance, and cognitive communication deficit. Review of care plan dated 10/16/24, revealed Resident #04 had the potential for decreased activity participation, involvement and or social isolation related to illness/disease process, immobility, and impaired decision making. Interventions included assist with arranging community activities and arrange transportation, encourage attendance and participation in activities, if the resident is physically unable to participate or facility cannot provide activities of interest provide alternate methods to keep the resident involved in the activity for example television programs, reading material, conversations, and field trips, offer a variety of activity types and locations to maintain interests, and provide a calendar of scheduled activities, and notify of any changes to the calendar. Review of Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #04 had severe cognitive impairment. Review of medical record for Resident #175, revealed an admitted [DATE] with diagnoses including but not limited to dementia, traumatic subdural hemorrhage without loss of consciousness, seizures, depression, and cannabis use. Review of care plan dated 12/13/24 for Resident #175, revealed impaired cognitive function/impaired thought processes related to resident meets criteria for secure dementia unit. Interventions included engaging the resident in simple, structured activities that avoid overly demanding tasks. Interview on 12/16/24 at 9:29 A.M. with Resident #175, revealed the resident did not think the facility had any activities. Resident #175 stated it gets boring at times in his room. Observation of the memory care unit on 12/16/24 at 10:08 A.M., revealed no activity calendar posted. Observation of the memory care unit on 12/16/24 at 11:40 A.M., revealed six residents in the common area and dining area on the memory care unit. Christmas music was playing on the television. Observation of the memory care unit on 12/16/24 at 2:47 P.M., revealed no activities going on in the memory care unit. Four residents were observed in the television room where a movie was playing; however, no residents were observed watching the movie. No activities calendar posted in the memory care unit and unable to determine if the movie was an activity. Interview on 12/17/24 at 8:25 A.M. with Certified Nursing Assistant (CNA) #493 stated they try to do activities in the memory care unit. CNA #493 stated they barely see the Activity staff. CNA #493 stated they usually have two aides on the memory care unit, and it can get overwhelming when there are behaviors, and attempting to do activities. Observation of memory care unit on 12/17/24 at 3:39 P.M., revealed snacks were supposed to be handled out. Observation revealed no snacks being served while five residents were observed seating in the dining/television room. A movie was started with none of the residents watching the television. Interview on 12/17/24 at 3:41 P.M. with CNA #441, verified there was no activity calendar posted in the memory care unit. CNA #441 stated normally the aides will do activities with the residents on the unit. CNA #441 stated that on second shift they do not do many activities. CNA #441 stated it is rare to see the activities department in the unit. CNA #441 verified it is hard to do activities with only two CNAs on the unit when they have behaviors. Observation of the memory care unit's bulletin board on 12/17/24 at 3:49 A.M. with CNA #441, revealed December 2024 activity calendar. CNA #441 verified the calendar was just posted. Observation of the memory care unit on 12/18/24 at 10:30 A.M., revealed CNA #441 playing connect four with two residents. Three other residents were observed in the television room. One resident was sleeping, one was sitting on the couch drinking water, and the other resident was sitting in a wheelchair holding a baby doll. The television was on with a movie playing. None of the residents were watching the television. Interview on 12/18/24 at 11:26 A.M. with Activity Director (AD) #868, revealed she has been working as AD for two months. AD #868 stated they go to the memory care unit once a day when she and the activity assistant were both working. AD #868 stated they do not work every day. AD #868 stated they take the daily chronicle to the memory care unit. AD #868 stated they post an activity calendar on the bulletin board of the memory care unit to let staff know what activities were scheduled. AD #868 verified she did not receive any special training for memory care unit activities. Review of December 2024 activity calendar in the memory care unit, revealed the following activities for the week of survey were: 12/16/24 at 9:45 A.M. daily chronicle, 11:00 A.M. hot chocolate, 12:30 P.M. lunch, 3:30 P.M. snack, 4:30 P.M. downtime, 5:30 P.M. dinner, and 7:00 P.M. wind down time. 12/17/24 at 9:45 A.M. daily chronicle, 11:00 A.M. refreshments, 12:30 P.M. lunch, 2:30 P.M. coffee hour, 3:30 P.M. snack, 4:30 P.M. down time, 5:30 P.M. dinner, and 7:00 P.M. wind down time. 12/18/24 at 9:45 A.M. daily chronicle, 11:00 A.M. lemonade and chats, 12:30 P.M. lunch, 2:30 P.M. craft, 3:30 P.M. snack, 4:30 P.M. down time, 5:30 P.M. dinner, and 7:00 P.M. wind down time. 12/19/24 at 9:45 A.M. daily chronicle, 11:00 A.M. refreshment, 12:30 P.M. lunch, 2:30 P.M. movie, 3:30 P.M. snack, 4:30 P.M. down time, 5:30 P.M. dinner, and 7:00 P.M. wind down time. Observation of the memory care unit on 12/19/24 at 9:47 A.M., revealed six residents in the dining room getting ready to do a craft. Residents were painting angels made out of clothes pins. Resident #175 was not attending the activity. Interview with Resident #175 stated he did not know there was an activity. Review of policy titled Activity Programs, not dated, revealed the activities program is provided to support the well-being of residents and to encourage both independence and community interaction. The activities program is ongoing and includes facility-organized group activities, independent individual activities and assisted individual activities. Activities are considered any endeavor, other than routine activities of daily living, in which the resident participates, that is intended to enhance his or her sense of well-being and to promote or enhance physical, cognitive or emotional health. Scheduled activities are posted on the resident bulletin board. Activity schedules are also provided individually to residents who cannot access the bulletin board for example bed bound or visually impaired residents.

Based on medical record review, review of physician and nurse practitioner (NP) progress notes, and staff interview, the facility failed to ensure physician visits were completed as required. This affected five (#60, #04, #12, #29, and #45) of the nine residents reviewed for physician visits. The facility census was 74. Findings include: 1) Review of the medical record revealed Resident #60 was admitted to the facility on [DATE]. Diagnoses included fibromyalgia, hypokalemia, hyperlipidemia, spinal stenosis, anxiety, upper abdominal pain, nausea with vomiting, gastro-esophageal reflux disease, diverticulitis of intestine, osteoporosis, osteoarthritis, chronic pain syndrome, unsteadiness on feet, muscle weakness, pain in right leg, pain in left leg, difficulty walking, and depression. Resident #60 was cognitively intact. Further review of the medical record, revealed Resident #60 was seen by the NP monthly from 02/29/24 through 12/16/24. There was no evidence of a physician visit with Resident #60 from 02/26/24 through 12/16/24. An interview with the Administrator on 12/19/24 at 1:42 P.M., verified the facility had no documented evidence, including progress notes or other documentation, to confirm Resident #60 was seen by a physician from 02/29/24 through 12/16/24. 45751 2) Review of medical record for Resident #04 revealed an admitted [DATE] with diagnoses including but not limited to Alzheimer's with late onset, unspecified fracture of right femur, dizziness and giddiness, orthostatic hypotension, dementia with other behavioral disturbance, and cognitive communication deficit. Resident #04 had severe cognitive impairment. Review of physician visit notes from March 2024 through December 2024, revealed Resident #04 was seen on 03/20/24, 04/26/24, and 10/19/24. Review of NP notes for September 2024 through December 2024, revealed Resident #04 was seen by the NP on 11/10/24, 10/21/24, 10/15/24, 10/10/24, 10/02/24, 09/26/24, 09/17/24, and 09/05/24. 3) Review of medical record for Resident #12 revealed an admitted [DATE] with diagnoses including but not limited to chronic obstructive pulmonary disease, type two diabetes, congestive heart disease, narcolepsy, anxiety, post-traumatic stress disorder, convulsions, depression, bipolar disorder, and paranoid schizophrenia. Resident #12 was cognitively intact. Review of NP notes from April 2024 through December 2024, revealed Resident #12 was seen on 09/04/24, 07/03/24, 07/01/24, 06/27/24, 05/30/24, 05/29/24, 05/23/24, 05/16/24, 05/14/24, and 04/10/24. Review of physician visit notes from March 2024 through December 2024, revealed Resident #12 was seen by the physician on 09/07/24 and 12/01/24. 4) Review of medical record for Resident #29 revealed an admitted [DATE] with diagnoses including but not limited to disorder of muscle, chronic obstructive pulmonary disease, type two diabetes, panic disorder, major depressive disorder, chronic pain, depression, anxiety, claustrophobia, low back pain, and muscle wasting. Resident #29 was cognitively intact. Review of physician visit notes from March 2024 through December 2024, revealed Resident #29 was seen by the physician on 04/06/24 and 11/16/24. 5) Review of medical record for Resident #45 revealed an admitted [DATE] with diagnoses including but not limited to fracture of right femur, major depressive disorder, cognitive communication deficit, anxiety, and chronic pain. Resident #45 had moderate cognitive impairment. Review of NP notes from March 2024 through December 2024, revealed Resident #45 was seen on 04/02/24. Review of physician visit notes from March 2024 through December 2024, revealed Resident #45 was seen on 06/07/24. Interview with Assistant Director of Nursing (ADON) #891 on 12/19/24 at 3:10 P.M. verified Resident #12 was only seen on 04/06/24, 09/07/24, and 12/01/24 by the physician. ADON #891 verified that Resident #45 was only seen by the physician on 06/07/24. ADON #891 verified Resident #04 was only seen by the physician on 03/20/24 and Resident #29 was seen by the physician on 11/16/24 and 04/06/24. Review of policy titled Physician Visits, not dated, revealed the attending physician must visit his/her patients at least once every 30 days for the first 90 days following the resident's admission, and then every 60 days thereafter. After the first 90 days, if the attending physician determines that a resident need not be seen by him/her every 30 days, an alternate schedule of visits may be established, but not to exceed every 60 days. A physician assistant or nurse practitioner may make alternating visits after the initial 90 days following the admission, unless restricted by law or regulation.

Based on observation, resident interviews, staff interviews, and policy review, the facility failed to ensure residents received food that was palatable and appetizing to them and which met their nutritional recommendations. This affected four (#57, #05, #62 and #61) residents out of the four residents reviewed for lunch. This had the potential to affect all but one resident (#174) who was identified by the facility as not receiving meals from the kitchen. The census was 74. Findings include: Review of medical record for Resident #57, revealed an admitted [DATE]. The resident was diagnosed with type 2 diabetes mellitus, peripheral vascular disease, and unspecified convulsions. Resident #57 was cognitively intact. Review of medical record for Resident #05, revealed an admitted [DATE]. The resident was admitted with diagnoses including paranoid schizophrenia, type 2 diabetes mellitus, and morbid obesity. Review of medical record for Resident #62, revealed an admitted [DATE]. The resident was admitted with diagnoses including type 2 diabetes mellitus, chronic obstructive pulmonary disease, and dementia. Review of medical record for Resident #61, revealed an admitted [DATE]. The resident was admitted with diagnoses including type 2 diabetes mellitus, essential hypertension, and major depressive disorder. Interview on 12/16/24 at 01:17 P.M. with Resident #57, revealed the hot food was cold. Observation on 12/18/24 at 11:31 A.M. of the lunch tray line with Dietary Manager (DM) #333, revealed the chicken breasts were holding at 176 degrees Fahrenheit (F) on the tray line. DM #333 confirmed the temperature. Interview on 12/18/24 at 12:06 P.M. with Resident #05, revealed she could not chew the chicken. Resident #05 stated the chicken was too dry and she wasn't able to eat it with her dentures. Resident #05 also revealed the Brussel sprouts were not good and today was a bad day for food. Interview on 12/18/24 at 12:18 P.M. with Resident #57, revealed the lunch tasted bad but it was warm. Interview with Resident #62 on 12/18/24 at 12:57 P.M., revealed the chicken was dry and the Brussel sprouts were mushy. Observation of a test tray on 12/18/24 at 12:37 P.M. with DM #333, revealed the chicken measured 135 degrees F, the vegetable rice measured 135 degrees F, and Brussel sprouts measured 142 degrees F. The test tray left the kitchen on 12/18/24 at 12:39 P.M. DM #333 stated the food leaving the kitchen should be at 135 degrees F or higher. DM #333 stated she wanted the residents to receive the food at 120 degrees F. Observation of the test tray on 12/18/24 at 12:44 P.M. with DM #333, revealed the chicken measured 120 degrees F, vegetable rice measured 135 degrees F, and the Brussel sprouts measured 135 F. Observation of the chicken with DM #333 revealed the chicken had a dry taste and texture. Interview with DM #333 and District Manager #666 verified the chicken was dry. Interview with Resident #61 on 12/18/24 at 1:00 P.M., revealed the chicken was dry. Resident #61 also revealed the Brussel sprouts had no taste. Observation at the same time revealed Resident #61 still had the chicken breast and Brussel sprouts on his lunch plate. Review of the Food Quality and Palatability policy dated 02/23 stated the food will be prepared by methods that conserve nutritive value, flavor, and appearance. Food will be palatable, attractive, and served at a safe and appetizing temperature.

Based on observation, interviews, and policy review, the facility failed to maintain the kitchen in a clean and sanitary condition. This affected all but one resident (#174) who was identified by the facility as not receiving meals from the kitchen. The census was 74. Findings Include: Observation of the kitchen on 12/16/24 at 10:59 A.M. with Dietary Manager (DM) #333, revealed the wall across from dishwasher had splattered food debris all over it and parts of the wall were chipping. Interview with DM #333 at the same time, verified the findings. Observation of the kitchen on 12/16/24 at 11:20 A.M. with DM #333, revealed the ventilation hood above the clean pan rack and stove top has paint strips hanging down from it. DM #333 verified the findings and stated someone cleaned too hard and now paint is hanging down. Follow up observation of the kitchen on 12/18/24 at 11:14 A.M. with District Manager #666, revealed the white paint strips were chipping from the ventilation hood above the stove top and clean dish rack. Interview with District Manager #666 at the same time verified the findings. Review of the Environment policy dated 09/2017 stated all food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition. The policy also stated, the Dining Services Director will ensure that the kitchen is maintained in a clean and sanitary manner, including floors, walls, ceilings, lighting, and ventilation. Review of the Food: Preparation policy dated 02/2023 stated dining services staff will be responsible for food preparation procedures that avoid contamination by potentially harmful physical, biological, and chemical contamination.

Based on observation, staff interviews, record review, and policy review the facility failed to ensure the kitchens walk-in cooler and reach-in cooler were working in a safe operable condition. This had the potential to affect all but one resident (#174) who was identified by the facility as not receiving meals from the kitchen. The census was 74. Findings include: Observation of the kitchen on 12/16/24 at 10:04 A.M. with the Dietary Manager (DM) #333, revealed the reach-in cooler had an ambient internal temperature of 44 degrees Fahrenheit (F). Interview with DM #333 at the same time, verified the reach-in cooler was 44 degrees F. Observation of the kitchen on 12/16/24 at 10:09 A.M. with DM #333, revealed the walk-in cooler had an ambient internal temperature of 47 degrees F. Interview with DM #333 at the same time verified the walk-in cooler was 47 degrees F. Observation of the walk-in cooler on 12/16/24 at 10:17 A.M. with DM #333, revealed the following temperatures: a) The cottage cheese was 44 degrees F. b) The cream cheese was 47 degrees F. c) The whole milk was 45 degrees F. d) The pre-sliced cheese in a plastic container was 49 degrees F. e) The packaged pre-sliced cheese was 43 degrees F. f) The sliced ham in a plastic container was 47 degrees F. g) The homemade coleslaw was 47 degrees F. h) The buffet ham log was 48 degrees F. Observation of the kitchen on 12/16/24 at 10:50 A.M. with DM #333, revealed the reach-in cooler had an ambient internal temperature of 44 degrees F . Interview with DM #333 at the same time verified the reach-in cooler was 44 degrees F. Observation of the kitchen on 12/16/24 at 11:33 A.M. with District Manager #666, revealed the reach-in cooler had an ambient internal temperature of 45 degrees F and the walk-in cooler had an ambient internal temperature of 46 degrees F. Interview with District Manager #666 at the same time verified the temperatures. District Manager #666 opened a pint of milk from the walk -in cooler and recorded a temperature of 45 degrees F. Observation on 12/17/24 at 8:47 A.M. with DM #333, revealed the walk-in cooler had an ambient internal temperature of 45 degrees F. Interview with DM #333 at the same time verified the walk-in cooler was 45 degrees F. DM #333 stated the reach-in and walk-in coolers should hold food at 41 degrees F or below. DM #333 stated they would have to dispose of the food. Review of the walk-in cooler temperature logs revealed the temperature of the walk-cooler is checked twice a day in the AM and PM. The log read on 12/01/24 was 44 degrees F in the AM, 12/02/24 was 45 degrees F in the AM, 12/03/24 was 46 degrees F in the AM, 12/04/24 was 45 degrees F in the AM and 42 degrees F in the PM, 12/05/24 was 45 degrees F in the AM, 12/05/24 was 42 degrees F in the PM, 12/06/24 was 46 degrees F in the AM, 12/07/24 was 46 degrees F in the AM, 12/08/24 was 46 degrees F in the AM, 12/09/24 was 46 degrees F in the AM, 12/10/24 was 45 degrees F in the AM, 12/11/24 was 46 degrees F in the AM, 12/12/24 was 46 degrees F in the AM and 42 degrees F in the PM, 12/13/24 was 46 degrees F in the AM and 42 degrees F in the PM, 12/14/24 was 47 degrees F the AM and 42 degrees F in the PM, 12/15/24 was 46 degrees F in the AM and 42 degrees F in the PM, and 12/16/24 was 46 degrees F in the AM. Review of the Equipment policy dated 09/2017 revealed all food service equipment will be clean, sanitary, and in proper working order. The policy also stated, all equipment will be routinely cleaned and maintained in accordance with manufacturer's directions and training materials. Review of the Food Storage - Cold Foods policy dated 02/2023 revealed all perishable foods will be maintained at a temperature of 41 degrees F or below, except during necessary periods of preparation and service.

Based on interviews, record review, policy review, the facility failed to ensure care conferences were completed timely. This affected six residents (#05, #07, #08, #12, #19, #29, and #45) of the 19 residents reviewed for care conferences. The facility census was 74. Findings include: 1) Review of medical record for Resident #07 revealed an admitted [DATE] with diagnoses including but not limited to hemiplegia/hemiparesis following cerebral vascular accident (CVA/stroke) affecting non-dominant right side, post-traumatic stress disorder (PTSD), bipolar disorder, schizophrenia, anxiety, and altered mental status. Review of Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #07 had moderate cognitive impairment. Review of progress notes including social service notes for Resident #07, revealed no documented evidence care conferences were held in May 2024 or August of 2024. 2) Review of medical record for Resident #08 revealed an admitted [DATE] with diagnoses including but not limited to atrial fibrillation, bipolar, dementia, and hypertension. Review of MDS assessment dated [DATE], revealed Resident #08 was cognitively intact. Review of progress notes including social service notes for Resident #08, revealed no documented evidence a care conference was held in July 2024. 3) Review of medical record for Resident #12 revealed an admitted [DATE] with diagnoses including but not limited to chronic obstructive pulmonary disease (COPD), type two diabetes, congestive heart failure (CHF), anxiety, post-traumatic stress disorder, depression, bipolar disorder, and schizophrenia. Review of MDS assessment dated [DATE], revealed Resident #12 was cognitively intact. Review of progress notes including social service notes for Resident #12, revealed no documented evidence a care conference was held in September 2024. 4) Review of medical record for Resident #19 revealed an admitted [DATE] with diagnoses including but not limited to brief dementia with severe agitation, type two diabetes, hypertension, anxiety, depression, and abnormal posture. Review of MDS assessment dated [DATE], revealed Resident #19 had severe cognitive impairment. Review of progress notes including social service notes for Resident #19, revealed no documented evidence care conferences were held in April 2024 and July 2024. 5) Review of medical record for Resident #29 revealed an admitted [DATE] with diagnoses including but not limited to disorder of muscle, COPD, type two diabetes, panic disorder, major depressive disorder, chronic pain, arthritis, depression, anxiety, and claustrophobia. Review of MDS assessment dated [DATE], revealed Resident #29 was cognitively intact. Review of progress notes including social service notes for Resident #29, revealed no documented evidence a care conference was held in August 2024. 6) Review of medical record for Resident #45 revealed an admitted [DATE] with diagnoses including but not limited to fracture of right femur, major depressive disorder, cognitive communication deficit, anxiety, and chronic pain. Review of MDS assessment dated [DATE], revealed Resident #45 had moderate cognitive impairment. Review of progress notes including social service notes for Resident #45, revealed no documented evidence care conferences were held in April 2024 and July 2024. Interview on 12/16/24 at 2:54 P.M. with Social Worker/Administrative Assistant (SW/AA) #869 verified that care conferences are to be completed upon admission and quarterly. SW/AA #869 verified that Residents (#07, #08, #12, #19, #29, and #45) care conferences were not held quarterly. 44454 7) Review of the medical record revealed Resident #05 was admitted to the facility on [DATE]. Diagnoses included paranoid schizophrenia, anxiety, depression, type II diabetes mellitus, asthma, rheumatoid arthritis, hypertension, and cognitive communication deficit. Review of MDS assessment dated [DATE], revealed Resident #05 was cognitively intact. Review of progress notes including social service notes for Resident #05, revealed no documented evidence a care conference was held or attempted in July 2024. An interview on 12/18/24 at 3:32 P.M. with the Director of Nursing (DON), verified Resident #05 did not have a quarterly care conference in July 2024. Review of the facility policy titled Care Planning - Interdisciplinary Team, not dated, revealed the interdisciplinary team was responsible for the development of resident care plans and residents, families, and/or legal representatives were encouraged to participate in the development of and revisions to the care plan. Care plan meetings would be scheduled at the best time of day for the resident and family if possible. If it was determined the participation of the resident or representative was not practicable, an explanation would be documented in the medical record.

Based on medical record review, staff interview, observations, and review of facility policy, the facility failed to develop a restorative passive range of motion program as recommended at the time of discharge from physical therapy for one (#23) of one resident reviewed for range of motion services. This resulted in actual harm to Resident #23 who developed an increase in contracture flexion to both knees. The facility identified a total of five residents currently residing in the facility with contractures. The facility census was 80. Findings include: Review of Resident #23's medical record revealed the resident was admitted on [DATE]. [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was assessed to have no functional range of motion deficits to upper or lower extremities. Review of the physical therapy evaluation dated 11/14/11 revealed the resident was assessed to have no functional range of motion deficits to bilateral knees. Review of a physical therapy evaluation dated 02/20/12, following re-admission from a hospital, identified the resident to have negative 20 degrees of left knee extension and no functional range of motion deficits to the right knee. Review of the document entitled "Rehabilitation Summary" dated 03/05/12, revealed the resident has passive range of motion lacking 44 degrees to full extension of the left knee. Review of the "Rehabilitation Summary" dated 03/09/12 revealed the resident was seen from 02/20/12 through 03/09/12 for bilateral knee stretching. This summary indicated the residents was being discharged from therapy as "progress has plateaued" and "will be discharged to restorative program" for bilateral lower extremity passive range of motion and stretch. review of the resident's medical record revealed [REDACTED]. There was no development of a restorative care plan. There was no documented evidence in the medical record that the resident received any type of restorative range of motion or stretch exercises as recommended by the physical therapist. Interview with the Director of Nursing on 10/03/12 at 8:23 A.M., verified the resident's medical record contained no documented evidence of the resident being evaluated for restorative range of motion following discharge from therapy on 03/09/12. She verified the document entitled "Rehabilitation Summary", dated 03/09/12 identified the resident was being discharged from physical therapy with recommendations to be placed on a restorative program for bilateral lower extremity passive range of motion and stretch. Observation of Physical Therapist #1 performing a range of motion assessment on 10/03/12 from 9:05 A.M. to 9:15 A.M., revealed Resident #23 to have a 55 degree flexion contracture on of the left knee and 25 degree flexion contracture of the right knee. Interview with Physical Therapist #1 immediately following this assessment verified the resident demonstrated an approximate 10 degree worsening of the flexion contracture to the left knee from the time of the resident's discharge from physical therapy on 03/09/12.