Every finding on record at Webster Manor Rehabilitation & Health Care Center

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who experienced a change in condition which included altered mental status, the facility failed to ensure he/she was provided with quality care and services that met professional standards of practice when: 1. nursing staff applied ice packs to Resident #1 when he/she became unresponsive without an order or nursing rationale and 2. nursing staff did not check Resident #1's Medical Orders for Life-Sustaining Treatment (MOLST) prior to initiating a Code Blue and requesting Emergency Medical Services to transfer him/her to the Hospital Emergency Department.Findings include:Resident #1 was admitted to the facility December 2021, diagnoses included progressive multiple sclerosis (nervous system disease disrupting signals between the brain and body), diabetes mellitus, atherosclerotic heart disease, hypertension and depression.Review of Resident #1's Minimum Data Set (MDS) assessment, dated 05/15/26, indicated he/she had moderate cognitive impairment and was; dependent on staff assistance for activities of daily living (ADL- bathing, dressing, grooming, transfer), administered insulin, Do Not Resuscitate (DNR), Do Not Intubate (DNI) Do Not Hospitalize (DNH), and his/her Health Care Proxy was not invoked.1. Review of the facility policy titled Cold Packs, dated 04/2015, indicated ice packs are applied by licensed nurses or licensed/certified therapy staff with a physician's order and/or professional judgement.Review of a report submitted via the Health Care Facility Reporting System (HCFRS), dated 07/07/26, indicated Resident #1 was packed in ice by a nursing home registered nurse (RN) for an unknown reason. The Report indicated Resident #1 was afebrile (without fever) and may be admitted to the hospital for hypothermia.Review of Resident #1's Hospital Emergency Department (ED) report, dated 07/04/26 indicated his/her temperature was 94 Farenheit upon arrival and his/her blood glucose level was 68 (normal 65-99).Review of Resident #1's Hospital Discharge summary, dated [DATE], indicated he/she had been admitted to the hospital due to metabolic encephalopathy (loss of brain function due to physical illness) secondary to bacteremia (bacteria in the blood) and was discharged back to the facility on [DATE].Review of Resident #1's Physician's orders for the Month of July 2026, indicated that there was no order for nursing to apply ice packs.Review of Resident #1's Care Plan, reviewed and revised with his/her 05/15/26 MDS, indicated there was no care plan area identified that included an intervention to apply ice packs.Review of Resident #1's Nurse Progress Note, dated 07/04/26, indicated that at 4:30 P.M., the Resident complained he/she was nauseas and dizzy, his/her blood sugar was checked and was 78, orange juice was administered and blood sugar recheck was 103. The Note indicated Resident #1 became unresponsive to verbal and tactile stimuli. The Note indicated Resident #1's vital signs were; temperature-97.8 F, pulse-80, blood pressure-148/78 and oxygen saturation was 89-90% on oxygen at two liters. The Note indicated Code Blue and 911 (Emergency Medical Services) was initiated.During a telephone interview on 08/04/26 at 1:45 P.M., Nurse #1 said on 07/04/26 at the beginning of the evening (3:00 P.M. to 11:00 P.M.) shift, she had checked Resident #1's blood sugar and it was 78. Nurse #1 said she gave Resident #1 orange juice with sugar and rechecked his/her blood sugar about half an hour later and it had gone up to 103. Nurse #1 said shortly after that time Resident #1 complained he/she was dizzy and nauseous and requested food but that when his/her meal came, Resident #1 was less responsive. Nurse #1 said she asked a CNA to bring her ice in small plastic bags which she applied to Resident #1's neck and right and left groin area because he/she was getting less responsive. Nurse #1 did not offer any additional explanation for her rationale for why she chose to place bags of ice on Resident #1, as a nursing intervention.During a telephone interview on 08/06/26 at 9:30 A.M. CNA #3 said Nurse #1 had asked him to obtain ice for Resident #1. CNA #3 said he filled three small bags with ice and delivered them to Nurse #1 but that he did not see how the ice was used.During an interview on 08/04/26 at 4:45 P.M., the Director of Nursing (DON) said her expectation of facility nurses is that when a patient is unresponsive, that they assess the resident and notify the Provider. The DON said Nurse #1 should not have applied ice to Resident #1.2. Review of the facility policy titled Communication of Code Status, dated 6/10/25, indicated when an order is written pertaining to a resident's presence or absence of an Advanced Directive, the directions will be clearly documented in designated sections of the medical record. The resident's code status will be reviewed at least quarterly and documented in the medical record.Review of Resident #1's Physician's orders for the Month of July 2026 indicated his/her Advanced Directives included: Do Not Resuscitate (DNR), Do Not Intubate (DNI), Do Not Hospitalize (DNH), Do Not Use Non-Invasive Ventilation, No Dialysis, No artificial nutritionReview of Resident #1's Medical Orders for Life-Sustaining Treatment (MOLST), dated 12/02/21, indicated he/she was, DNR, DNI, DNH, Do Not Use Non-Invasive Ventilation, No Dialysis, No Artificial Nutrition.Review of Resident #1's Advanced Directive care plan, reviewed and revised with his/her 05/15/26 MDS, indicated he/she was DNR, DNI, DNH, do not use noninvasive ventilation, No dialysis, No artificial nutrition.Review of Resident #1's Nurse Progress Note, dated 07/04/26, indicated at 4:30 P.M., the Resident complained he/she was nauseas and dizzy. The Note indicated the Nurse obtained a blood sugar measurement of 78, administered orange juice and rechecked Resident #1's blood sugar and obtained a measurement of 103. The Note indicated the Resident became unresponsive to verbal and tactile stimuli, vital signs were obtained and documented as follows; temperature-97.8, pulse-80, blood pressure-148/78 and oxygen saturation 89-90% on oxygen at two liters. The Note indicated Code Blue and 911 (Emergency Medical Service) was initiated and that the Nurse Practitioner, Health Care Proxy and Director of Nursing had been updated.Nurse #1 said on 07/04/26 during the evening shift, she had observed Resident #1 become unresponsive. Nurse #1 said she administered a sternal rub, to which he/she did not respond and called out to another nurse to call Code Blue. Nurse #1 said when the other nurses arrived, they took Resident #1's vitals and that they were stable. Nurse #1 said one of the nurses checked Resident #1's MOLST form and told her that he/she was DNR, DNI and Do Not Hospitalize. Nurse #1 said that she did not call and update the Provider of Resident #1's altered mental status or his/her vital signs until after Resident #1 had been transferred to the ED.During an interview on 08/04/26 at 4:45 P.M., the Director of Nursing (DON) said Nurse #1 should have assessed Resident #1, checked his/her MOLST form, and notified the Provider prior to initiating Code Blue and calling 911 for emergency transport to the hospital but that Nurse #1 had not.On 08/04/26, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction, with an effective date of 07/14/26, which addressed the areas of concern as evidenced by:A. Resident #1 was readmitted to the facility and continues to be monitored by staff.B. On 07/06/26 the Director of Nursing and/or designee developed a Quality Improvement Plan including audits, re-education of nurses, and reporting the area of concern to Quality Assurance Performance Improvement Committee.C. On 07/07/26 the Director of Nursing and/or designee completed re-education of Nurse #1 regarding identifying resident change of condition, following physician orders, appropriate use of (ice) cold packs and hypoglycemic protocol.D. On 07/07/26 the Social and/or designee conducted a facility wide audit of Advanced Directives including MOLST forms, Health Care Proxy, and Physician orders.E. On 07/08/26 the Director of Nursing and/or designee completed an in-service for all Nurses regarding clinical management of hyper/hyperglycemia, following physician orders, assessment and documentation of change of condition, proper indication and risks for use of cold packs.F. On 07/14/26 the Director of Nursing and/or designee conducted a Code Blue Drill including Nurse's verification of residents Code status, initiation of CPR and initiation of Emergency Medical Services.G. The Director of Nursing and/or designee are responsible for overall compliance.

Based on observations, interviews, and record reviews, the facility failed to provide an environment free of potential safety hazards for three units (Lake Unit, [NAME] Unit and Tapestry Unit), out of three total units. The facility also failed to ensure the safe storage of medications for one Resident (#62) and failed to ensure one Resident (#30) was provided with a Physician's ordered diet, out of a total sample of 29 residents. Specifically, the facility failed to: Ensure the Soiled Utility Rooms on the [NAME] and Tapestry Units, which contained trash bins, the laundry chutes, specimen refrigerators and broken glass receptacles, were locked and not accessible to unauthorized persons and residents with wandering behaviors, placing them at increased risk for potential injury and infection.For Resident #62, who resided on the Lake Unit: -safely and properly store prescribed medications Gabapentin (prescription medication used to relieve neuropathic (nerve) pain) and Acidophilus (probiotic used to promote the growth of good bacteria in the body) when the medications were left within reach at the Resident's bedside, placing the Resident at risk of inappropriately accessing and using the medications. -ensure that medications were not readily accessible to Resident #62 and other unauthorized individuals, when the Resident did not have an assessment or Physician's order for self-administration of medications and the medications were observed unattended and within close proximity of the Resident in his/her bedroom. For Resident #30, provide and administer the appropriate consistency diet as recommended by the Speech Language Pathologist (SLP) and ordered by the Physician, placing the Resident at increased risk of choking, aspiration (inhalation of solids/liquids into the lungs) and infection. Findings include: 1. Review of the facility's policy, revised 6/16/25, indicated: -Soiled utility rooms shall be used for storing soiled linen and trash. These rooms shall be identified as hazardous areas with the appropriate protections (i.e. signage, sprinklers, self-closing doors, clear path of entrance/egress into room). On 5/18/26 at 8:47 A.M., on the [NAME] Unit, the surveyor was able to open the door to the room labeled, Soiled Utility without entering a code. The surveyor observed a strip of tape covering the door frame where the lock would engage/latch. The surveyor further observed a trash bin, open laundry chute, a specimen refrigerator without a lock, and a bucket labeled broken glass with no lid containing soiled gloves, inside the soiled utility room. On 5/18/26 at 8:52 A.M., on the Tapestry Unit, the surveyor was able to open the unlocked door to the Soiled Utility room without entering a code. The surveyor observed a strip of tape covering the door frame where the lock would latch. The surveyor further observed a trash bin, open laundry chute, a specimen refrigerator without a lock, and an unlabeled bucket with no lid containing soiled gloves in the soiled utility room. On 5/19/26 at 9:19 A.M., the surveyor observed on the [NAME] Unit that the Soiled Utility room was unlocked, and staff members were entering and leaving the soiled utility room. During an interview on 5/19/26 at 9:19 A.M., Certified Nurse Aide (CNA) #6 said there are residents on the [NAME] Unit who are at risk of wandering. CNA #6 said it was important to have locks on some of the doors, such as the Soiled Utility room, to keep residents from entering those areas. CNA #6 said the residents who are at risk for wandering could enter the Soiled Utility room and there are dangers in the room, such as the open laundry chute. CNA #6 said it is important to keep the doors locked for the safety of the residents who may enter these rooms. CNA #6 said there is a communication binder for maintenance at the nurse's station and any staff member can enter requests for maintenance. During an interview on 5/19/26 at 9:28 A.M., the Assistant Director of Nurses (ADON) said she just added the maintenance request into the log to have the lock changed on the [NAME] Unit. The ADON said the doors should be locked because the residents should not have access to the Soiled Utility room. The ADON said the room contains broken glass and an unlocked specimen refrigerator. The ADON further said the door had been broken and needed replacement before. The surveyor and the ADON reviewed the maintenance binder and found no requests to have the lock replaced prior to today. The ADON said all staff would be responsible for notifying maintenance if the lock to the soiled utility room door was broken. Review of the Maintenance Communication Binder on 5/19/26 at 9:32 A.M., indicated requests from 2/25/26. The surveyor observed there were no maintenance requests to fix the Soiled Utility room door on the [NAME] Unit until 5/19/26 (after the surveyor inquired). On 5/19/26 at 9:30 A.M., the surveyor observed on the Tapestry Unit that the Soiled Utility room was unlocked. The surveyor observed staff members entering and leaving the room. During an interview on 5/19/26 at 9:30 A.M., CNA #5 said there are residents on the Tapestry Unit who are at risk of wandering. CNA #5 said it was important to keep residents from entering some areas, such as the Soiled Utility room, to keep the residents at risk of wandering safe. CNA #5 said the open laundry chute and specimen refrigerator were not safe for residents. CNA #5 said she thinks the lock to the Soiled Utility room was broken and broken items can be written into the maintenance log by any staff member. Review of the Maintenance Communication Binder on the Tapestry Unit on 5/19/26 at 10:32 A.M., indicated requests from 2/26/26. The surveyor observed there were no maintenance requests to fix the soiled utility room door on the Tapestry Unit until 5/18/26 [sic] (after the surveyor inquired). On 5/19/26 at 1:00 P.M., while on the Tapestry Unit, the surveyor observed a resident wandering into another resident's room after he/she removed a stop sign barrier placed across the resident's doorway. The surveyor then observed the same resident wander to the stairway door near the main dining room and attempt to open the door by turning the handle and pushing against the door with force several times. During an interview on 5/20/26 at 1:51 P.M., the Director of Nursing (DON) said the Soiled Utility rooms should be locked because the rooms contain the laundry chute, a specimen refrigerator, soiled linens and trash. 2. Review of the facility policy titled Medication Administration, dated 5/9/25, included but was not limited to: *Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection.-Observe resident consumption of medications. Review of the facility policy titled Medication Storage Room/Medication Cart, dated February 2018, included but was not limited to: *The facility provides pharmaceutical services that are conducted in accordance with accepted ethical and professional standards of practice and that meet applicable Federal, State and Local Laws, rules and regulations. -Medications are stored primarily in a locked mobile medication cart which is accessible only to licensed nursing personnel.-Storage of other medications will be limited to a locked medication room. Review of the facility policy titled Self Administration of Medication, dated July 2015, included but was not limited to: *Residents are afforded the right to self-administer their own medications, upon request, and after determination the practice is safe. If the resident elects to self-administer his/her own medications, an evaluation of their cognitive, physical and visual ability to perform this task is conducted to ensure accurate and safe medication management. If the evaluation indicates the resident can safely perform required functions, self-administration of medications is allowed. If unable to safely perform this task, the licensed staff, or trained medication aides/technicians, as allowed by State law, will administer.-Upon admission, readmission, annually, quarterly, and change of condition, provide the resident/responsible party with a two-part document entitled self-administration of medications informed consent and evaluation. Part I asks the resident/responsible party to identify and document whether they wish to self-administer medication or wish the appropriate trained staff to administer their medication.-Evaluate the resident's cognitive, physical, and visual ability to self-administer medications, if they have requested to do so (Part II of self-administration of medications informed consent and evaluation). -Complete the self-administration evaluation and document whether the resident can safely self-medicate or is unable to safely self-medicate. If the resident can't safely self-medicate, document the reasons why.-Inform the resident/responsible party of the decision.-If approved, obtain a physician's order for self-administration of medications.-Update the care plan for self-medication to include where medications will be stored, documentation of self-administration, and location of the drug administration. -Perform resident education of all required self-medication protocols and document any education.-Mark the MAR (Medication Administration Record) for each medication being self-administered for daily compliance monitoring purposes. (Indicate that the resident has self-administered). Resident #62 was admitted to the facility in May 2026 with diagnoses including Major Depressive Disorder, low back pain, generalized anxiety disorder and other abnormalities of gait and mobility. Review of Resident #62's Minimum Data Set (MDS) Assessment, dated 5/12/26, indicated that the Resident was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of a total possible score of 15. Review of Resident #62's May 2026 Physician orders included:-Acidophilus Oral Capsule (Lactobacillus), Give 1 capsule by mouth three times a day for probiotic, initiated 5/12/26.-Gabapentin Oral Tablet 600 milligrams (mg) (Gabapentin), give 1 tablet by mouth every 8 hours for pain, initiated 5/12/26. On 5/18/26 at 1:40 P.M., the surveyor observed Nurse #3 enter Resident #62's bedroom, place a plastic medication cup containing one large white oval tablet and one white capsule on the Resident's bedside table. Nurse #3 then exited the Resident's bedroom, walked towards the medication cart positioned at the entrance of the Resident's room, and then left the area outside of Resident #62's room. During an interview on 5/18/26 at 1:45 P.M., Resident #62 said that the medication cup on his/her bedside table were his/her scheduled medications. Resident #62 said the large white oval tablet was Gabapentin 600 mg and the large white capsule was a probiotic. Resident #62 was observed to pick up the medication cup containing the medications, place the medication cup to his/her mouth and swallow the medications while Nurse #3 was not present in the room. On 5/18/26 at 1:47 P.M., the surveyor observed Nurse #3 return to the medication cart positioned at the entrance of Resident #62's room and enter the Resident's bedroom. During an interview on 5/18/26 at 1:56 P.M., Nurse #3 that she should not have left the medications unattended at Resident #62's bedside table when she exited the Resident's room. Nurse #3 said there was a risk that Resident #62 may not have taken the medication. Review of Resident #62's clinical records included a self-administration of medications assessment that indicated Resident #62 does not desire to self-administer medications. During an interview on 5/19/26 at 8:15 A.M., Unit Manager (UM) #1 said that her expectation was that Nurses should not leave medication at the bedside for residents to self-administer. UM #1 said that Nurses should ensure that medications were administered before leaving residents rooms. UM #1 also said that it was unsafe to leave medication at the Resident's bedside if Nurses were not present as other residents could take the medication. During an interview on 5/19/26 at 4:18 P.M., the Director of Nursing (DON) said that her expectation for nursing staff administering medication was that Nurses would stay with the resident and ensure that the resident takes the medication unless the resident had self-administering medications assessment. The DON said the risk to Resident #62 having the medication at the bedside was that the Resident could throw the medication away and not take the medication as ordered. 3. Resident #30 was admitted to the facility in May 2021 with diagnoses including hemiplegia and hemiparesis from a cerebral infarction affecting the left non-dominant side, muscle weakness, need for assistance with personal care and dysphagia (difficulty swallowing). Review of the Minimum Data Set (MDS) Assessment, dated 5/1/26 indicated Resident #30: -had moderate cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of 12 out of a possible 15 points -required substantial/maximum assistance of staff with eating -was on a mechanically altered diet Review of Resident #30's Physician's orders indicated the following: -Controlled Carbohydrate diet, Pureed texture, Nectar/Mildly Thick consistency, Aspiration Precautions, lip plate, liberalized to allow pancakes and French toast with syrup, initiated 4/15/26. -Aspiration precautions every shift, initiated 5/25/21. -Assist with meals, initiated 3/20/26. On 5/18/26 at 9:20 A.M., the surveyor, who was at the nurse's station, heard loud, wet sounding coughing. The surveyor entered Resident #30's room where the coughing was heard and observed Certified Nurse Aide (CNA) #1 seated at Resident #30's bedside. Resident #30 was lying upright in bed and was holding a regular cup of thickened milk in his/her right hand. CNA #1 was holding a lip plate that contained a regular muffin and scrambled eggs and was assisting Resident #30 with the breakfast meal. Review of the Resident #30's meal ticket for breakfast indicated the following: -Pureed . Nectar thick/mildly thick (liquids) -can have pancakes and French toast with syrup -aspiration precautions -feeding assistance -soft breads allowed On 5/18/26 at 12:37 P.M., the surveyor heard wet sounding coughing from Resident #30's room. The surveyor entered the Resident's room and observed Resident#30 lying upright in bed during the lunch meal. CNA #1 was observed seated at the bedside and was assisting Resident #30 with a pureed consistency meal. During an interview at the time, CNA #1 said the Resident had a regular muffin and scrambled eggs for breakfast today but has the pureed lunch meal. The Resident was observed to have a wet cough multiple times, his/her face was red, and his/her left eye was watering. CNA #1 said the Resident has been coughing like this for months but usually does not cough like he/she did at breakfast and at lunch. CNA #1 said the Resident's diet has been pureed for a while. During an interview on 5/20/26 at 10:59 A.M., the SLP said Resident #30 was admitted to the facility with dysphagia and had some general declines since admission. The SLP said when Resident #30 was discharged from speech therapy, his/her diet consistency was pureed with nectar thick liquids and allowance of pancakes and French toast with syrup. The SLP said the staff alerted her that Resident #30 was having some difficulty with meals on Monday (5/18/26) and she was completing an evaluation and doing some education with the facility staff. The SLP said Resident #30 should not have received a regular muffin and regular consistency scrambled eggs on 5/18/26, and that could increase the risk of Resident #30 aspirating. The SLP said the resident meal trays are checked in the kitchen and then again by the Nurse and the CNA prior to delivery. The SLP said she was not sure why Resident #30 received the incorrect diet consistency, but when she notices this happening, she contacts the kitchen to receive the correct meal. During an interview on 5/20/26 at 2:11 P.M., the Food Service Director (FSD) said the kitchen prepares pureed scrambled eggs to be served daily for residents who need them daily. The FSD said Resident #30 was on a pureed diet consistency and should not have received regular scrambled eggs and a regular consistency muffin.

Based on observation, and interview, the facility failed to maintain a clean, sanitary, and homelike environment for residents residing on three (Lake, [NAME] and Tapestry) out of three units. Specifically, the facility failed to ensure that resident rooms and common areas were maintained in clean, homelike condition, and were in good repair when:-on the Lake Unit, ceiling tiles in resident rooms were missing or stained.-on [NAME] Unit, a strong urine odor was present and ceiling tiles in resident rooms were missing or stained.-on the Tapestry Unit, a broken call light that was constantly ringing, multiple resident rooms and the Unit dining room had scuffed walls, doors, and baseboards in disrepair. Findings include: Review of the facility policy titled Resident Rights, dated 6/10/25, included the following under Safe Environment: -The Resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safety. On 5/18/26 at 4:07 P.M., the surveyor observed the Lake Unit shower room had an Out of Order, Do Not Use sign posted. The surveyor further observed the shower room did not have a shower head or shower handle valve. On 5/19/26 from 9:11 A.M. to 9:22 AM, the surveyor observed the following on the Lake Unit: -room [ROOM NUMBER] had brown stains on the ceiling tiles in the bedroom -room [ROOM NUMBER] had brown stains on the ceiling tiles in the bedroom -room [ROOM NUMBER] the bathroom had a missing ceiling tile above the tub/shower -room [ROOM NUMBER] had brown stains on the ceiling tiles in the bathroom -room [ROOM NUMBER] had brown stains on the ceiling tile in the bedroom and bathroom -room [ROOM NUMBER] had brown stains on the ceiling tiles in the bedroom During the initial tour of the [NAME] Unit on 5/17/26 from 7:55 A.M. through 8:30 A.M., the surveyor observed the following: -Strong smell of urine upon entering the unit. -in room [ROOM NUMBER], several discolored ceiling tiles. The base of the toilet in the bathroom was largely discolored and black. Two bags of dirty linen and trash were on the floor next to the Resident's bed and the Resident was observed lying in the bed at the time. -Resident Rooms: 201, 205, 211, 212, 213, 214, 215, 216, 217, 218, and 219 had several discolored and stained ceiling tiles. During follow-up observations on the [NAME] Unit on 5/18/26 at 7:37 A.M., and 5/19/26 at 9:20 A.M., the surveyor observed the strong smell of urine remained upon entering the unit. On 5/17/26 at 8:15 A.M., the surveyor observed a loud ringing noise throughout the Tapestry unit. During an interview at the time, Unit Manager (UM) #2 said there was one room, (316) with a broken call light. UM #2 said the call light cord was pulled out and they were unable to turn the light off so it just rings constantly and has been like this for about a week. UM #2 said the facility had ordered parts but until the parts came in the call light would continue to ring. On 5/18/26 between 8:19 AM and 10:25 AM the surveyor observed the following on the Tapestry Unit: -Broken call light in room [ROOM NUMBER] continued to ring audibly at the nurse's station. -The metal baseboard covers outside the doorway of the activity/dining room had a thick layer of brown dust and dirt. One of the corners of the baseboard was bent outward and there were dark stains and debris on the floor under and on the outside edges of the baseboard. -There were a dirty cup and plate on the windowsill of the window in the hallway outside the activity/dining room. -room [ROOM NUMBER] had a hole cut in the ceiling tile and there was rubber tubing coming out of the hole over Resident #37's television. During an interview at the time, Resident #37 said that the tube was to drain water leaking from the roof. Resident #37 said that the facility would put a big bucket under the tubing when it was leaking to catch the water. -room [ROOM NUMBER] had black scraped markings and chipped paint on the bathroom door. The wall closest to the window had scratches and missing paint with the drywall showing. The baseboard had a layer of dust and was bent outwards. -Review of the Tapestry Unit Maintenance Communication Book on 5/19/26 at 10:49 A.M., indicated a maintenance request to fix the constant ringing call light on 5/6/26 and 5/11/26. On 5/20/26 from 5:40 through 6:00 P.M., the surveyor observed the following on the Tapestry Unit: -Rooms 305 through 307 had numerous discolored/stained ceiling tiles -room [ROOM NUMBER] had numerous discolored/stained ceiling tiles, and the outer light cover was missing on the Bed B. -room [ROOM NUMBER] had broken window blinds and a strip of broken baseboard. -numerous resident rooms had scuffed walls, doors and baseboards in disrepair. -The Tapestry Unit dining room had approximately 14 discolored/stained ceiling tiles. There was missing/scuffed/chipped paint on the walls, the air conditioning unit located in the wall had copious amounts of debris in the inner vent, and the overhead lighting had visible bugs in the fixture. On 5/20/26 at 6:00 P.M., during the dinner meal on the Tapestry Unit, the meals were observed served on meal trays placed in front of the 12 - 15 residents in the dining room with no tablecloths in use. During an interview on 5/19/26 at 1:17 P.M., the Administrator said the facility attempted to resolve the continuous loud audible beeping noise on the Tapestry Unit today, but it did not work. The Administrator said the continuous audible beeping was an environmental concern and could be annoying for staff and residents on the unit. During an interview on 5/20/26 at 4:24 P.M., the Administrator said he was aware there are problems with the facility maintaining a home-like environment and there is no system for tracking what is identified as needing to be fixed. The Administrator said they will use the funds available to fix bigger environmental concerns such as heating and plumbing and they are working on fixing the shower rooms. The Administrator said that the environment was important to the residents because the facility is their home. The Administrator said the current environment is not homelike for the residents. During an interview on 5/20/26 at 6:32 P.M., with the Director of Nursing (DON) and the Administrator, the DON said the expectation for resident dining during the dinner meal was for the staff to use tablecloths with the resident's food served off the meal trays.

Based on interviews, and record review, the facility failed to make prompt efforts to adequately resolve grievances identified from Resident Council for two out of three Resident Council meeting minutes reviewed. Specifically, the facility failed to investigate the Resident Council grievances, summarize pertinent findings or conclusions about the identified grievances relative to call lights not being answered and laundry not being returned to residents in a timely manner. Findings include: Review of the facility's policy Resident Council Meetings, dated 6/30/25 and revised 6/30/25, indicated: -the facility shall act upon concerns and recommendations of the Council, make attempts to accommodate recommendations to the extent practicable, and communicate its decisions to the Council. Review of the facility's Grievance Policy, undated, indicated: -Upon completion of the review, the grievance officer should document the following: -the date the grievance was received-a summary of the resident's grievance -steps taken to investigate the grievance -a summary of the pertinent findings or conclusions regarding the grievance -a statement as to whether the grievance was confirmed or not -any corrective action taken or to be taken in response -The QAPI committee shall be responsible for identifying care and service issued that necessitate further committee action, and for the development and implementation of as needed corrective action. Review of the facility's policy Personal Clothes Policy and Procedure, undated, indicated: -Normal turn-around time for the return of the clothing is 72 hours. On 5/18/26 at 11:09 A.M., during the Resident Council meeting held with the surveyor, the residents indicated they feel there is no follow through of the grievance process. Review of Resident Council meeting minutes, dated 2/25/26, indicated the following grievances identified by the residents: -second shift staff were not answering call lights in a timely manner. -laundry was coming back slowly. Review of Resident Council concern follow-up, dated 2/25/26, relative to call lights indicated: -Second shift call lights are being answered slower. Review of Department Head Resolution relative to call lights, dated 3/4/26, did not indicate call light wait time was investigated or confirmed. Review of Resident Council concern follow-up, dated 2/25/26, relative to laundry indicated: -Residents feel their laundry is coming back slowly. Review of Department Head Resolution relative to laundry, dated 3/4/26, indicated: -The Department Head will talk with staff about the policy and ask that they speed up delivery process as much as possible. Review of the facility's Scored Call Light Audit - Compliance Tool, dated March 2026, did not indicate the unit or shift audited and included a score of 90% (compliant). The facility was unable to provide the survey team with information on what actions were taken after concerns about the timeliness of laundry delivery was identified in the 2/25/26 Resident Council meeting. Review of Resident Council meeting minutes, dated 4/30/26, indicated the following grievances identified by the residents: -Residents state that Certified Nursing Aides (CNAs) will come in and turn off their call light and not return. -Some residents feel that their clothes are still coming back too slowly. Review of Resident Council concern follow-up, dated 4/30/26, relative to call lights indicated: -Residents state that staff come in to answer call lights, turn them off and do not always return. Review of Department Head Resolution relative to call lights, dated 5/4/26, indicated: -That is not protocol; if the call light is on the staff will answer; if staff need assistance, they will leave the light on to remind them to return to that room. -Call light audits will be done if this keeps happening; call lights should be answered within three to five minutes. Review of Resident Council concern follow-up, dated 4/30/26, relative to laundry indicated: -Clothing is coming back slowly. Review of Department Head Resolution relative to laundry, dated 4/30/26, indicated: -The Department Head will in-service staff on the 72-hour policy to ensure that clothing is delivered in a timely manner. The facility was unable to provide the survey team with information on what actions were taken after concerns about the timeliness of call response and laundry delivery were identified in the 4/30/26 Resident Council meeting. During interviews on 5/19/26 at 11:22 A.M. and 2:50 P.M., the Activities Director (AD) said grievances can be written with the residents following resident council or concern sheets are generated and given to the respective department head(s) responsible for addressing the concern. The AD said the concern sheets are filled out and discussed at morning meeting, which includes but is not limited to the Administrator, the Director of Nursing (DON) and facility department heads. The AD said the concern sheets are given to the appropriate department head(s) and they are responsible for addressing the concern. During an interview on 5/20/26 at 3:27 P.M., the Grievance Officer said she uses the same process for both written grievances and Resident Council concern sheets. The Grievance Officer said that call lights can be an issue, but sometimes it is a perception of time, which she further clarified that the residents feel they are waiting longer than what is factual, but she does not have documentation of this. The Grievance Officer also said that she works in multiple nursing homes and call lights being answered in a timely manner is a concern that may never be fixed. Relative to laundry returning to residents in a timely manner, the Grievance Officer said she has spoken to residents and their families regarding the laundry policy and procedure, but despite the education provided to residents and their families, it continues to be a concern. The Grievance Officer said regardless of any repeat concerns brought up in Resident Council, staff will continue to address the concern each time, and if necessary, the concern could be brought to Quality Assurance & Performance Improvement (QAPI) committee. During an interview on 5/20/26 at 3:39 P.M., the Director of Housekeeping and Laundry said the policy for laundry turnaround is 72-hours. The Director Housekeeping and Laundry said there is one staff person responsible for washing, drying, and sorting personals Monday through Friday. The Director of Housekeeping and Laundry said he does not have a staff person working Sundays to deliver personal laundry, but there is a staff person who works every other Saturday for personal laundry. The Director of Housekeeping and Laundry said the facility does not outsource any laundry services and that may be the reason laundry may take so long to return to residents. The Director of Housekeeping and Laundry said if a resident was without clothing and waiting for laundry to return, this would be a dignity concern. Regarding laundry concerns, the Director of Housekeeping and Laundry said he would provide verbal in-service to staff (not documented) and if concerns continued to arise, he would alert the Administrator. The Director of Housekeeping and Laundry said there is no current QAPI relative to laundry concerns, but it would be beneficial to have one, and that it would be beneficial to educate residents and their families upon admission about the laundry process. During an interview on 5/20/26 at 4:15 P.M., the Administrator said the residents' concerns about laundry come and go. The Administrator said the facility changed staff for personal laundry and provided verbal and written education regarding personal laundry. The Administrator said there was no QAPI in place for laundry at this time. The Administrator said they have discussed providing education for families regarding the laundry process, but this had not yet occurred. Regarding call lights, the Administrator said that his call light audit, dated March 2026, occurred on the day shift and his plan was to expand to additional shifts.

Based on observations, interviews, and record reviews, the facility failed to ensure dignity was maintained for two Residents (#11 and #30), out of a total sample of 29 residents, and during the dining experience on one unit (Tapestry Unit), out of three units observed.Specifically, the facility failed to ensure that:Resident #11 was dressed in clothing, not a hospital gown, when his/her preference was to be dressed daily in personal clothing.Resident #30 was provided with dignity/privacy when he/she was uncovered in bed with under briefs viewable to others, and signage indicating specific level of assistance with feeding were posted above the Resident's bed and in view of others. Residents in the Tapestry Unit dining room were dressed in clothing, not hospital gowns, when dining with other residents during the dinner meal. Findings include:Review of the facility policy titled Resident Rights, reviewed/revised 6/10/25, indicated the following:-the resident has a right to be treated with respect and dignity, including:>the right to retain and use personal possessions, including clothing, -the resident has a right to personal privacy and confidentiality of his or her personal and medical records .>personal privacy includes accommodations, medical treatment, written and telephone communication, personal care . 1. Resident #11 was admitted to the facility in February 2026 with diagnoses including abnormal gait and mobility and history of falls. Review of the Activities of Daily Living (ADL) Care Plan, initiated 2/21/26, indicated Resident #11 required assistance from staff with dressing activities. Review of the Minimum Data Set (MDS) Assessment, dated 2/24/26, indicated Resident #11:-understands and is understood-was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 13 out of a possible 15 points-exhibited no behaviors-had upper extremity range of motion deficits on one side-required partial to moderate assistance of staff with upper body dressing-was dependent on staff for lower body dressing On 5/17/26 at 11:23 A.M., the surveyor observed Resident #11 dressed in a hospital gown and seated in a wheelchair in his/her room. On 5/18/26 at 8:46 A.M. and at 9:02 A.M. and at 12:40 P.M., the surveyor observed Resident #11 dressed in a hospital gown and seated in a wheelchair in his/her room. During interviews at 9:02 A.M. and 12:40 P.M., Resident #11 said he/she did want to wear a hospital gown, had clothing go down to laundry approximately four weeks prior to be washed and it had not been returned. Resident #11 said he/she told numerous staff about his/her laundry that was not returned. Resident #11 said he/she had shirts but did not have pants available to wear. Resident #11 said laundry staff told him/her that his/her clothing should be brought up by tomorrow (5/19/26). Resident #11 said he/she did not want to leave his/her room or attend activities because he/she was wearing a hospital gown. Resident #11 said he/she was embarrassed and did not feel comfortable. On 5/19/26 at 11:03 A.M., the surveyor observed Resident #11 dressed in a hospital gown and seated in a wheelchair in his/her room. During an interview at the time, the Resident said laundry staff told him/her that they will bring up his/her pants tomorrow (5/20/26). Resident #11 said it had been four weeks since his/her laundry had been sent down to be laundered and that he/she did not have pants to wear. On 5/20/26 at 8:55 A.M., the surveyor observed Resident #11 dressed in regular clothing (shirts/pants) and seated in a wheelchair in his/her room. During an interview at the time, Resident #11 said the Certified Nurse Aide (CNA) found clothing in his/her closet and he/she was not sure when it was delivered. During an interview on 5/20/26 at 9:32 A.M., Laundry Personnel #2 said she does the laundry sorting and deliveries to all of the units. Laundry Personnel #2 said Resident #11 had been asking for a specific pair of pants and she had not seen them yet. Laundry Personnel #2 said she delivered a pair of pants to the Resident yesterday and she was going to deliver several shorts and some pants for him/her today. During an interview on 5/20/26 at 4:09 P.M., the surveyor relayed the observations relative to Resident #11 to the Administrator who said he would check laundry to see if he could locate some of the Resident #11's laundry items. The Administrator said it would be a dignity concern if Resident #11 was not provided regular clothing if he/she did not want to wear a hospital gown. The Administrator said if the Resident did not have clothing available to wear, he would expect the nursing staff to alert administration so they could follow up and that he had not been made aware that there had been any issues with Resident #11 not receiving his/her clothing to be dressed. 2. Resident #30 was admitted to the facility in May 2021 with diagnoses including hemiplegia and hemiparesis from a cerebral infarction (stroke) affecting the left non-dominant side, muscle weakness, and need for assistance with personal care. Review of the ADL Care Plan, initiated 5/25/21, indicated Resident #30 required assistance from staff with dressing activities. The care plan also included the following:-provide privacy and promote dignity . Review of the MDS Assessment, dated 5/1/26, indicated Resident #30:-had moderate cognitive impairment as evidenced by a BIMS score of 12 out of a possible 15 points-had upper range of motion deficits on one side-was dependent on staff with dressing and repositioning On 5/17/26 at 10:38 A.M., the surveyor observed Resident #30 awake and lying in bed. A sign stating the following was observed taped to the wall behind the Resident's bed:-Resident is an assist for feeding. Must be boosted all the way before elevating the head of bed. On 5/18/26 from 8:35 A.M. through 9:07 A.M., the surveyor observed the following:-Resident #30 was visualized from the hallway lying in bed with his/her eyes closed. The privacy curtain was not pulled, and the Resident's legs and adult brief were exposed and could be visualized from the hallway. -The meal and beverage carts were positioned immediately outside of the Resident's room, and several staff were observed passing meal trays and preparing beverages from this location. -signage relative to feeding remained taped to the wall over the head of the Resident's bed. -at 9:07 A.M., a CNA was observed to enter Resident #30's room and leave a covered meal tray on the over the bed table positioned next to the bed and exited the room. Resident #30 remained with his/her legs and adult brief exposed. On 5/18/26 at 10:09 A.M., the surveyor observed Resident #30 lying in bed with eyes closed. The signage relative to feeding remained taped to the wall behind the head of the Resident's bed. During an interview on 5/20/26 at 10:59 A.M., Rehabilitation Staff #5 said she thinks she put up the signage about specific feeding instructions above Resident #30's bed. Rehabilitation Staff #5 said she would put signs up in residents' rooms because there was a lack of follow-through with the staff and she uses the signs as a reminder of specific care needs. Rehabilitation Staff #5 said Resident #30 was a high aspiration risk and Rehabilitation Staff #5 had completed education with the staff and added specific interventions in the Resident's plan of care but had also put signage up to alert staff because of the lack of follow through. During an interview on 5/20/26 at 12:29 P.M., the surveyor relayed observations relative to Resident #30 to the Director of Nursing (DON). The DON said Resident #30 has the right to be uncovered if he/she chooses but if so, the facility should ensure that the Resident's privacy curtain be drawn. The DON said signage indicating Resident information about their care should not be posted as this would be considered a privacy concern. 3. On 5/20/26 at 6:00 P.M., the surveyor observed the dinner meal on the Tapestry Unit. Approximately 12 - 15 residents were present in the unit dining room, and six residents were observed dressed in hospital gowns while seated with other residents during the dinner meal. During an interview on 5/20/26 at 6:32 P.M., with the Administrator and DON, the surveyor relayed the observation from the dinner meal on Tapestry Unit. The DON said the surveyors' observations were not what the facility administration expected from the facility staff and that residents should not be wearing hospital gowns during the dinner meal in the unit dining room. The DON said residents would receive evening care after the dinner meal, so residents should not be dressed in hospital gowns at this time.

Based on observations, interviews, and record reviews, the facility failed to provide urinary catheter care and services that meet professional standards for one Resident (#12), of two applicable residents reviewed with urinary catheters, out of a total sample of 29 residents. Specifically, for Resident #12, the facility failed to ensure the Physician's orders were followed when irrigating the Resident's urinary catheter and also failed to ensure the urinary catheter tubing remained off the floor, placing the Resident at risk of urinary catheter complications, contamination and infection. Findings include: Review of the facility policy titled Catheter Care, reviewed/revised 5/2/25, indicated it was the policy of the facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain privacy when indwelling catheters are in use. Review of the facility policy titled Catheter Irrigation, reviewed/revised 5/2/25, indicated urinary catheters may be irrigated to provide for and maintain constant urinary drainage or to administer medication. The policy also included the following: -Urinary catheters shall be irrigated by a licensed nurse using sterile technique, under the orders of the Physician. -Routine irrigation is not recommended. -Orders shall include the type and amount of irrigating solution or medication. -irrigation through a closed system is the preferred method of irrigation. -For irrigation through a drainage port: >disconnect the catheter from the drainage bag >disinfect the catheter drainage port with an antiseptic pad and allow to dry. >attach a syringe, maintaining sterility of the tip, to the drainage port. >instill the irrigating solution into the catheter as directed and then draw back on the plunder to evacuate any clot or debris. >empty the syringe into the container >continue to irrigate as directed until clear or clot free >connect a new drainage bag as directed >dispose of all used supplies in the appropriate receptacle >remove gloves and perform hand hygiene Resident #12 was admitted to the facility in December 2021 with diagnoses including Benign prostatic hyperplasia (BPH) with lower urinary tract symptoms, Multiple Sclerosis, hydronephrosis, and neuromuscular dysfunction of the bladder. Review of Resident #12's comprehensive care plan included the following: -Urinary Catheter Care Plan, initiated 3/6/22, that indicated the Resident's increased risk of infection and complications related to catheter use. The care plan included the following interventions: >provide catheter care per policy (3/6/22) >irrigation with Normal Saline solution as ordered for when the catheter is blocked (3/6/22) Review of the Minimum Data Set (MDS) Assessment, dated 2/13/26, indicated Resident #12: -was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 14 out of a possible 15 points, -was dependent on staff for toileting needs -had an indwelling urinary catheter Review of Resident #12's May 2026 Physician's Orders included the following: -Irrigate the foley catheter as needed with 30 milliliters (ml) of Normal Saline if not draining PRN (as needed) for blockage/leakage, initiated 2/9/22 -Monitor foley catheter at bedside drainage every shift that is not touching the floor and it is in the privacy bag every shift, initiated 1/15/24 On 5/19/26 at 12:45 P.M., the surveyor observed Resident #12 dressed in a hospital gown and seated in a wheelchair positioned next to the bed. The Resident's urinary drainage bag was observed positioned under the wheelchair seat and the catheter tubing was observed on the ground. The catheter tubing contained dark red urine. During an interview at this time, Resident #12 said he/she did not have any discomfort from the catheter, but that there was blood in the catheter earlier and was unsure if there still was. During an interview on 5/19/26 at 1:06 P.M., the surveyor relayed observations of the dark red urine in Resident #12's catheter tubing. Nurse #4 said Resident #12 had some blood in the catheter tubing a few weeks ago and when she irrigated the tubing, it cleared up. Nurse #4 said sometimes the Resident's catheter tubing gets pulled because it is positioned around the Resident's leg or gets pinched, which causes pressure and can cause the bleeding. Nurse #4 said that once the Resident's catheter is repositioned and irrigated, there have been no issues. Nurse #4 said Resident #12 requires assistance of two staff with transfers and that she has had to provide education to staff on ensuring the catheter tubing is not wrapped around the Resident's leg or caught. On 5/19/26 at 2:12 P.M., the surveyor observed Nurse #4 complete the irrigation of Resident #12's catheter tubing and observed the following: -Nurse #4 entered the Resident's room with supplies. Upon entering the room, Nurse #4 opened a package containing a urinary drainage bag and tubing, a bottle of sterile water and a package containing a piston syringe with a blub top and placed the open packages on the Resident's overbed table and end of bed. -Nurse #4 took the piston syringe and drew up 30 mls of sterile water from the container and put the piston syringe back in the opened packaging. -Nurse #4 placed a towel under the Resident's wheelchair. The Resident's urinary drainage bag was observed under the wheelchair seat and the catheter tubing remained on the floor. With ungloved hands, Nurse #4 lifted up the Resident's urinary tubing from the floor and said the urine in the Resident's catheter tubing was clear now. -Nurse #4 then went into the bathroom, gathered a trash receptacle, performed hand hygiene and donned a gown and gloves. -Nurse #4 disconnected the Resident's urinary drainage bag and tubing from the drainage port. Nurse #4 showed the surveyor the urinary drainage bag which contained dark red urinary contents and then placed the urinary drainage bag and tubing in the trash receptacle. -Nurse #4 discarded her gloves in the trash receptacle and donned new gloves (without performing hand hygiene). -Nurse #4 inserted the piston syringe containing the sterile water into the Resident's catheter drainage port, informed the Resident that it was going to be cold, and then inserted the solution into the drainage port. -Resident #12 was observed to jerk and say ouch at this time, Nurse #4 asked him/her if they were okay and then continued to irrigate the catheter port with the sterile water. -Nurse #4 then removed the piston syringe and attached new tubing with the urinary drainage bag to the drainage port. Nurse #4 hung the urinary drainage bag under the Resident's wheelchair and ensured the catheter tubing remained off the floor, doffed her gown and gloves and performed hand hygiene. -The surveyor observed the drainage in the tubing to be light yellow in color. During an interview immediately following the procedure, Nurse #4 said prior to the irrigation procedure, Resident's catheter tubing was not wrapped around his/her leg or pinched, but the catheter tubing was on the floor and should not have been because of the increased risk of infection. Nurse #4 said she should have performed hand hygiene after removing her gloves and prior to donning new gloves, but she did not. Nurse #4 said the contents in the Resident's drainage bag prior to the irrigation procedure was hematuria (bloody urine). During a follow-up interview on 5/20/26 at 10:45 A.M., Nurse #4 said she used sterile water to irrigate Resident #12's urinary catheter and the Physician's order indicated to use normal saline solution. Nurse #4 further said the Physician's order indicated to irrigate the Resident's catheter if was blocked or leaking and it was not blocked or leaking yesterday when the irrigation was performed. Nurse #4 said that when she observed hematuria in the catheter tubing and/or urinary drainage bag, she should have updated the provider to get a physician's order to irrigate the Resident's catheter. Please refer to F880.

Based on observations, interviews, and record reviews, the facility failed to ensure devices to assist with limited range of motion (ROM) were applied for three Residents (#78, #8, and #30), of three applicable residents reviewed for ROM, out of a total sample of 29 residents, placing the Residents at risk for worsening contractures and/or ROM, pain and skin impairment. Specifically: 1. For Resident #78, the facility failed to ensure that a Physician's ordered splint was applied to the Resident's left hand. 2. For Resident #8, the facility failed to ensure a palm guard was applied to the Resident's right hand as recommended by the Occupational Therapist (OT) and ordered by the Physician. 3. For Resident #30, the facility failed to ensure a palm guard was applied the Resident's left hand and that a splint was applied to the Resident's left elbow, as recommended by the OT and ordered by the Physician. Findings include: Review of the facility policy titled Splints/Orthotics/prosthetics, dated April 2015, included: -Residents will receive splint/orthotic/prosthetic devices as deemed appropriate by the physician and rehabilitation services. -Nursing staff will apply/remove the designated splint/orthotic/prosthetic device during scheduled wearing times. -If the residents refuses the device, notify the rehab (rehabilitation) department, physician, and responsible party. -Document evaluations and notify MD (Medical Doctor) of any abnormalities. 1. Resident #78 was admitted to the facility in September 2022 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side. Review of Resident #78's Comprehensive Care Plan for potential skin alteration and integrity related to impaired mobility, initiated 9/28/22 and revised on 6/23/24, indicated: -Resident to wear L (left) Leeder splint for tone mngt (management), on at all times.off for AM/PM care. Remove splint for skin hygiene. Check skin integrity Q (every) shift. Review of Resident #78's recent Minimum Data Set (MDS) Assessment, dated 3/13/26, indicated: -has moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 10 out of a possible score of 15. -has no rejection of care. -has ROM impairment on one side. -substantial/maximal assist with upper body dressing. Review of Resident #78's May 2026 Physician's orders, dated 7/22/25 indicated: -wear L (left) Leeder splint for tone mngt (management). -On at all times.off for AM/PM care. -Remove splint for skin hygiene. -Check skin integrity Q shift. Every shift. On 5/17/26 at 12:39 P.M., the surveyor observed a green hand splint on the seat of a chair located at the bottom of Resident #78's bed. Resident #78's left arm was covered by a blanket. During an interview at the time, Resident #78 said he/she was not wearing any splints. On 5/18/26 at 7:47 A.M., the surveyor observed Resident #78 lying in bed and no splint was observed on the Resident's left hand. A green hand splint was observed on the chair at the bottom of the Resident's bed. During an interview at the time, Resident #78 said he/she did not wear a splint for his/her hands but used to wear a splint on his/her left hand. On 5/18/26 at 10:50 A.M., the surveyor observed Resident #78 was not wearing a splint on his/her left hand. The Resident's hand was observed to be flexed at the wrist and the fingers curled in a fist with the outside surface of the fingers, including the first and second knuckles resting flat on the mattress. During an interview at the time, Resident #78 said he/she used to wear a hand splint for the left hand all the time, but no one has put the splint on for a while. Resident #78 said he/she would wear it if it was offered to be put on. When the surveyor indicated the green hand splint located on the chair at the bottom of the Resident's bed, the Resident said that was the splint he/she used to wear. During an interview on 5/18/26 at 2:08 P.M., Unit Manager (UM) #2 said if someone has an order for a splint to be worn at all times, then the expectation would be that the Resident should be wearing the splint. UM #2 said if the Resident was refusing to wear the splint, the staff should be documenting the refusal so the order could be reassessed. UM #2 said she did not know if Resident #78 had been wearing a left hand splint, but if the Resident had an active order, then he/she should be wearing the splint. During an interview on 5/20/26 at 11:27 A.M., the Director of Rehabilitation (DOR) said Resident #78 would sometimes take the splint off and put it aside on the bed. The DOR said if the splint was on the chair, the Resident could not have taken it off and put it on the chair by themself. The DOR said Resident #78 should be wearing the splint as the Physician's orders stated. The DOR said if the Resident is removing the splint the staff should be re-approaching the Resident throughout the day to re-apply the splint. The DOR said she would not necessarily expect the nursing staff to contact her if the Resident was not wearing the splint. The DOR said she would not change the order because it is important that Resident #78 wears the splint for contracture management if not all the time, then as much as possible. 2. Resident #8 was admitted to the facility in June 2015 with diagnoses including aphasia following cerebral infarction (stroke), hemiplegia and hemiparesis affecting the right dominant side, abnormal posture, and pain in the right hand. Review of Resident #8's Comprehensive Care Plans included the following: -Potential Alteration in Skin Integrity, initiated 7/11/18, and included the following intervention: Splint- apply right hand roll to right hand, on after A.M. (morning) care and off after P.M. (nighttime) care, as tolerated for tone management. Remove splint for skin hygiene. Check skin integrity every shift (initiated 9/23/25 and revised 5/3/26) Review of the MDS Assessment, dated 5/1/26, indicated Resident #8: -has severe cognitive impairment as evidenced by a BIMS score of three out of a possible 15 points. -had no rejections of care during the assessment period. -had upper and lower extremity range of motion deficits on one side. -required substantial to maximum assistance with dressing. Review of Resident #8's May 2026 Physician's orders indicated: -Splint: Apply right hand tan hand roll to right hand, on after A.M. (morning) care and off after P.M. (evening) care as tolerated for tone management. Remove Splint for skin hygiene. Check skin integrity every shift, initiated 9/23/25 Review of the May 2026 Treatment Administration Record (TAR) indicated Resident #8's right hand splint was signed off as administered (applied) daily from 5/4/26 through 5/16/26, and on 5/18/26 by the nursing staff, and was refused by Resident #8 on 5/17/26. On 5/18/26 at 10:29 A.M., the surveyor observed Resident #8 dressed and seated in a wheelchair during activities. There was no splint applied to the Resident's right hand. On 5/18/26 at 1:14 P.M., the surveyor observed Resident #8 using his/her left hand to self-propel the wheelchair down the hallway. There was no splint applied to the Resident's right hand. During an interview on 5/20/26 at 10:07 A.M., the surveyor and the DON reviewed Resident #8's May 2026 TAR. During an interview at the time, the DON said that the check marks on the TAR indicated that the Nurses applied the splint to the Resident's right hand on 5/4/26 through 5/16/26, and 5/18/26. The DON said the OT went around yesterday (5/19/26) to ensure the residents had their devices. The DON said if a resident refuses to wear a Physician's ordered device or the device no longer fit, she would expect the Nurse to contact therapy and document in the resident's clinical record so that a therapy screen could be completed. The DON said relative to Resident #8, the Physician's order indicated for the right hand splint (hand roll) to be applied during morning care and to remove the splint during evening care. The DON said evening care would occur prior to bedtime and would be completed sometime after the dinner meal. The DON said if Resident #8's device was not applied as recommended by the OT and as ordered by the Physician, the Resident's right-hand contracture could worsen and there could be issues with the Resident's skin integrity. During an interview on 5/20/26 at 11:23 A.M., Rehabilitation Staff #4 said Resident #8 had an increased risk of skin issues in his/her right hand, had previous skin issues in the right hand, and should have the splint applied. Rehabilitation Staff #4 said the Resident was able to remove the right-hand splint at times, so they make sure they have multiple splints for him/her. Rehabilitation Staff #4 said the nursing staff should be monitoring to ensure Resident #8 has the right-hand splint in place, and if the Resident refused to wear the device, the staff should re-attempt its application. Rehabilitation Staff #4 said that if the Resident continues to refuse the application of the right-hand splint, the nursing staff should document and inform the rehabilitation staff. Rehabilitation Staff #4 said it was important for Resident #8 to wear the right-hand splint because he/she was at risk for worsening right hand contracture and impaired skin. 3. Resident #30 was admitted to the facility in May 2021 with diagnoses including hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side, muscle weakness, need for assistance with personal care and contracture of the left hand. Review of the Physiatry Note dated 3/12/26, indicated the following relative to Resident #30: -activities of daily living (ADL) and mobility dysfunction secondary to cerebral vascular accident (stroke) affecting the left non-dominant side. -continue care of left upper extremity contractures, orthotics with goal to prevent worsening of contracture . Review of the MDS Assessment, dated 5/1/26, indicated Resident #30: -has moderate cognitive impairment as evidenced by a BIMS score of 12 out of a possible 15 points. -had upper range of motion deficits on one side. -required assistance from staff with activities of daily living care and repositioning. Review of Resident #30's May 2026 Physician's orders indicated: -Splint: Apply left hand roll and left pillow on elbow area, on with evening (P.M.) care and off with morning (A.M.) care for tone management as tolerated. Remove splint for skin hygiene. Check skin integrity every shift, initiated 3/19/26. -Splint: Apply left elbow orthotic and hand roll, on with morning care and off with evening care. Remove splint for skin hygiene. Check skin integrity every shift, initiated 3/19/26. Review of the May 2026 TAR indicated Resident #30's left elbow orthotic and left-hand roll were signed off by the nursing staff that the devices were applied from 5/4/26 through 5/19/26 during the day shift. On 5/17/26 at 10:38 A.M., the surveyor observed Resident #30 lying upright in bed. The Resident's left arm was bent at the elbow, and his/her left hand was closed in a fist and was resting against the Resident's chest. The surveyor observed that there were no devices (left elbow orthotic or hand roll) applied to the Resident's left elbow and left hand. During an interview at the time, Resident #30 said he/she was unable to open his/her left hand and that he/she was unaware of any devices to be used currently to assist with his/her contractures. Resident #30 said he/she was currently not working with the rehabilitation staff. On 5/18/26 at 8:35 A.M., the surveyor observed Resident #30 lying upright in bed. The Resident's left arm was bent at the elbow, and the left hand was closed in a fist and was laying against the Resident's chest. The surveyor observed that there was no hand roll in the Resident's left hand. On 5/18/26 at 12:03 P.M., the surveyor observed Resident #30 lying upright in bed. The Resident's left arm was bent at the elbow, and the left hand was closed in a fist and resting on the Resident's chest. The surveyor observed that there were no devices applied on the Resident's left elbow or left hand. On 5/19/26 at 12:48 P.M., the surveyor observed Resident #30 lying upright in bed and was being assisted with the lunch meal by CNA #5. The Resident's left arm was bent at the elbow, and the left hand was observed to have a hand roll applied. During an interview at the time, Resident #30 said the staff applied the left-hand roll today. CNA #5 said Resident #30 was supposed to wear the left-hand roll all the time. During an interview on 5/19/26 at 1:57 P.M., Nurse #4 said Resident #30 was admitted to the facility following a stroke. Nurse #4 said Resident #30 had devices for his/her left hand and elbow but sometimes refuses to wear them. Nurse #4 said if the Resident refuses to wear the devices, they would update the Provider and document in the clinical record that he/she refused them. Nurse #4 said the therapy staff saw Resident #30 today and applied the left-hand roll, but the Resident refused the left elbow splint. During an interview on 5/20/26 at 11:13 A.M., Rehabilitation Staff #4 said Resident #30 last received rehabilitation services in March 2026 and at that time he/she received a new elbow splint. Rehabilitation Staff #4 said the Resident had some resistance to splinting and devices but was mostly agreeable to wearing them. Rehabilitation Staff #4 said Resident #30 did not understand the purpose of the recommended devices and sometimes required multiple re-approaches for device placement. Rehabilitation Staff #4 said she did not receive any notification that Resident #30 refused to wear the ordered devices and that if the Resident was refusing to wear the devices, the nursing staff should be documenting refusals. Rehabilitation Staff #4 said without the Physician ordered left elbow splint and hand roll, the Resident could have worsened contractures and skin breakdown.

Based on interview, observation, and record review, the facility failed to assist in obtaining routine dental care for one Resident (#67) out of a total sample of 29 residents. Specifically, for Resident #67, the facility failed to provide assistance in scheduling routine dental services, placing the Resident at risk for unidentified dental disease, difficulty chewing, and deteriorating oral health. Findings include: Review of the facility policy titled Consultant Services, dated 4/2015, included but was not limited to: -the Facility will identify and facilitate consultant services to meet the resident's needs, to ensure optimum care for each resident though consultant services. -For dental consults, all families will sign a release form upon admission indicating whether they do or do not want the [facility] to make these arrangements. Resident #67 was admitted to the facility in November 2024, with diagnoses including history of nicotine dependence, dysphagia, and Diabetes. Review of Resident #67's Minimum Data Set (MDS) Assessment, dated 5/1/26, indicated the Resident was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 14 out of a total possible score of 15. During an interview on 5/17/26 at 9:43 A.M., Resident #67 said he/she had not been seen by a Dentist since being admitted to the facility but should be seen because he/she was admitted with a broken tooth that needed to be fixed or pulled out. Resident #67 said he/she told the staff but was unable to recall which staff member. Resident #67 said the broken tooth made it difficult for him/her to chew and pointed to a broken tooth in his/her right, upper oral cavity. Review of the Resident's medical record failed to include evidence that Resident #67 had been offered dental services since admission to the facility. Review of the Resident's recent Oral Health Assessment signed by the Director of Nursing (DON), dated 4/30/26, indicated Resident #67 had no broken teeth and no known chewing problems. During an interview on 5/19/26 at 11:15 A.M., the Assistant Director of Nurses (ADON) said Resident #67's medical record had been reviewed and there was no evidence to support that the Resident was offered routine dental services at the time of admission. During an interview on 5/19/26 at 12:49 P.M., MDS Nurse #1 said Resident #67's Dental Services Consent Form was located in the Resident's medical record, that the form was dated 11/2024 but was not signed by the Resident. MDS Nurse #1 said when she identified that Resident #67 was not offered dental services since admission, she completed a Consent Form, together with the Resident, and the Resident consented to dental services on 5/14/26. MDS Nurse #1 said that Resident #67 had been receiving dental care outside the facility when he/she was first admitted and therefore did not need dental services at the time of admission. During a telephone interview on 5/20/26 at 10:44 A.M., Resident #67's Health Care Proxy (HCP- person appointed to make medical decisions when someone is unable to do so for themselves) said Resident #67 had never left the facility for any dental care services or been seen for routine dental care since admission. The HCP further said that Resident #67 was admitted to the facility with a broken tooth and the tooth needed a crown. During a follow-up interview on 5/20/26 at 10:51 A.M., the ADON said Resident #67's Dental Services Consent Form should have been completed at the time of admission with the admitting Nurse. The ADON said the risk to the Resident not being seen timely by the Dentist could be oral infection and/or pain.

Based on observations, interviews, and record review, the facility failed to ensure that cold food and beverage were provided at safe and appetizing temperatures to residents on one unit ([NAME] Unit), out of three total resident units, to prevent potentially hazardous (food that requires time/temperature control for safety to limit the growth of pathogens such as bacterial or viral organisms capable of causing disease) foodborne illness. Specifically, the facility failed to provide milk and butterscotch pudding at safe and appetizing temperatures at the lunch meal for residents eating lunch on the [NAME] Unit, increasing the residents' risks for reduced food/fluid intake and foodborne illness. Findings include: Review of the facility's policy titled Record of Food Temperatures, last reviewed 6/30/25, included but was not limited to the following: -Potentially Hazardous Cold Food will be kept at or below 41 degrees Fahrenheit (F). -Place cold menu items .over an ice bath, in a pan (preferably on a separate cart) and not beside a steam table. During the initial pool selection on 5/17/26, several residents on the [NAME] Unit stated concerns relative to inconsistent food temperatures at the time of service. On 5/20/26 at 12:38 P.M., the lunch cart arrived on the [NAME] Unit. The test tray was removed from the lunch cart, after all residents on the unit had been served at 12:48 P.M., and the surveyor and the Director of Social Services observed the following: -mashed potato and gravy: 147.2 F, seasoned and palatable-sliced carrot: 130 F, palatable, easy to chew -ham and gravy: 135.6 F, seasoned, palatable and easy to chew-butterscotch pudding with whipped topping: 65.2 F, taste like butterscotch pudding, but was not cold. -container of milk: 68.2 F, tasted creamy but was not cold. During an interview on 5/20/26 at 1:41 P.M., the Food Service Director (FSD) said milk and pudding should be served between 35 - 37 F. The FSD said warm milk products could make residents sick, may decrease a resident's food consumption, and would not be nice to taste. The FSD said that the kitchen gets very hot and the milk products should probably be pulled out in smaller batches to maintain a colder temperature.

Based on observations, interviews, and record reviews, the facility failed to implement infection control standards to provide a safe, sanitary and comfortable environment for two Resident's (#12 and #14) out of a total sample size of 29 residents. Specifically;1. Nurse #2 and Certified Nurse Aide (CNA) #1 failed to follow Physician orders relative to Enhanced Barrier Precautions (EBP's - the use of protective gowns and gloves during high contact care activities that may provide opportunity for transmission of medication resistant organisms through staff hands and/or clothing) for Resident #12 who had an indwelling urinary device, increasing the risk of infection to the Resident. 2. The Infection Preventionist (IP) failed to perform hand hygiene between glove changes during wound care and wear a gown during direct care activities for Resident #12, increasing the risk of infection to the Resident. 3. The facility staff failed to ensure Resident #12's urinary catheter tubing remained off the floor, and Nurse #4 failed to wear gloves and perform hand hygiene during catheter care increasing the risk of contamination and potential infection. 4. For Resident #14, Rehabilitation Services Staff #1 and #2 failed to ensure that EBP was appropriately utilized when providing splint care and services for the Resident with enteral feeding (medical device used to provide nutrition and liquid nourishment directly into the stomach/intestines through a gastrointestinal feeding tube, g-tube ) to mitigate the risk of organism transmission and the spread of infection to the Resident and other residents within the facility. Findings include: Review of the facility policy titled Enhanced Barrier Precautions (EBP), revised 7/14/22, included but was not limited to the following: -EBP's require the use of gown and gloves for certain residents during specific high-contact resident care activities which there is an increased risk for transmission of Multi Drug Resistant Organisms (MDRO's- pathogens, such as bacteria or fungi, that have developed resistance to multiple antimicrobial drugs, making infections difficult to treat). High contact resident care activities include device care and wound care. -EBP's will also be implemented for residents with wounds or indwelling medical devices (catheter). -Signage will be posted on the door or wall outside the resident's room indicating the need for EBP's, the required personal protective equipment (PPE-equipment such as gowns, gloves, facemasks, and eye protection used to make a protective barrier to prevent the transmission of pathogens from one person to another), and the high contact resident care activities that require the use of gown and gloves. -Carts with the appropriate PPE will be placed outside the resident's room. -EBP's will be continued while the qualifying condition or indwelling device is still active or in use. 1. Resident #12 was admitted to the facility in December 2021 with diagnoses including Extended Spectrum Beta Lactamase (ESBL) resistance of the urine, neuromuscular dysfunction of bladder with indwelling catheter, Moisture Associated Skin Damage (MASD) (to a specific perineum area), and Diabetes. Review of Resident #12's May 2026 Physician's orders included: -EBP's related to ESBL/Foley (a specific type of indwelling urinary catheter) every shift for prevention/protection, effective 10/2/24. -Normal Saline (NS), Triad (a topical wound care product used to manage low to moderate levels of wound drainage and useful for wounds that are difficult to dress due to irregular surfaces or moisture exposure, such as the perineum) daily (to a specific area of the perineal area) leave open to air (LOTA) every day shift (7:00 A.M. - 3:00 P.M.) for wound care. Do not scrub, effective 3/6/26. On 5/18/26 at 12:00 P.M., the surveyor observed signage posted on the wall outside Resident #12's room as follows: >STOP Enhanced Barrier Precautions STOP >EVERYONE MUST -Clean their hands, including before and after entering and when leaving the room. >PROVIDERS AND STAFF MUST ALSO -Wear gloves and a gown for the following high contact Resident Care Activities. --Dressing, Bathing --Transferring --Changing Linens --Providing Hygiene --Device care or use: urinary catheter, feeding tube, central line, tracheostomy --Wound Care On 5/18/26 at 12:27 P.M., the surveyor observed wound care being provided to Resident #12 as follows: -Nurse #2 and CNA #1 performed hand hygiene with alcohol-based hand sanitizer, donned gloves, and entered Resident #12's room, neither staff donned gowns. -CNA #1 lifted the Resident's legs on the bed and placed the Resident's catheter drainage bag and tubing on the Resident's mattress. -Nurse #2 then exposed the Resident's perineum area, confirmed that the Resident had an open wound on the perineum area and applied Triad to the open wound tissue, without donning gowns prior to wound care. -Nurse #2 and CNA #1 then positioned the Resident for comfort, adjust the bed linens for privacy, and CNA #1 returned the Resident's catheter drainage bag and tubing to the right side of the Resident's bed frame. -Nurse #2 and CNA #1 then removed their gloves, performed hand hygiene with alcohol-based hand sanitizer and exited the Resident's room. During an interview at the time, Nurse #2 said Resident #12 had signage posted outside the room for EBP's. Nurse #2 said Resident #12 had ESBL in the urine, an open wound on the perineum, and an indwelling urinary catheter. Nurse #2 said both she and CNA #1 should have had gowns on during wound care to prevent the spread of infection to Resident #12, facility staff, and other residents in the facility. During an interview on 5/18/26 at 1:55 P.M., the Infection Preventionist (IP) said Resident #12 was ordered for EBP's because he/she had a history of ESBL in the urine and an indwelling urinary catheter. The IP said all staff are to gown and glove when providing direct care to Resident #12. The IP said Resident #12 was at risk for infection when staff did not follow EBP's and infections could be spread to another resident on the unit when gowns were not used by staff. 2. Review of the facility policy titled, Clean Dressing Technique, undated, included but was not limited to the following: -Non-sterile dressings protect open wounds from contamination. -Licensed staff members will use clean dressing technique for all dressing changes unless otherwise specified by the Medical Doctor (MD). -Check physicians order for current, correct treatment. -Sanitize hands. -Establish clean field. -Gather supplies and place on clean field, including several clean gloves. -Inform resident what you are going to do. -Provide Privacy. -Sanitize hands and apply gloves. -Remove old dressing and discard in plastic bag. -Remove gloves, sanitize hands and apply clean gloves. -Cleanse wound with solution ordered. Cleanse from the center of the wound to the periphery. -Observe the wound .this is the best time to measure the area. -Remove gloves, sanitize hands an apply clean gloves. -Apply any medication ordered to dress the wound. -Remove gloves and sanitize hands. On 5/19/26 at 12:06 P.M., the surveyor observed the IP provide wound care to Resident #12 as follows: -The IP performed hand hygiene with alcohol-based hand sanitizer, donned clean gloves and a gown, and entered the room and explained the procedure to the Resident. -The IP established a clean surface and set out supplies of saline, gauze, measuring tape and Triad. -The IP lifted the Residents right leg on the bed and placed the Resident's urinary catheter drainage bag and tubing on the bed. -The IP removed her soiled gloves, discarded the gloves into the trash can and donned new gloves without performing hand hygiene. -The IP exposed the Resident's perineum area and observed the open wound, then cleansed the open wound with NS and gauze and discarded the gauze into the trash can. -The IP measured the open wound to be 0.7 centimeters (cm) x (by) 0.4 cm x 0.01cm. -The IP removed her soiled gloves, discarded into the trash can and donned new gloves without performing hand hygiene. -The IP applied Triad to the Resident's open wound, then discarded all trash into the trash can and doffed (removed) her used gown and used gloves. -The IP donned new gloves at the Resident's doorway without performing hand hygiene or donning a new gown. -The IP then returned to the Resident's bedside, re-positioned the Resident's legs, repositioned the Resident's catheter drainage bag and tubing from the bed to the right side of the Resident's bedframe, adjusted the Resident's linens for privacy, then removed her soiled gloves without performing hand hygiene and exited the Resident's room. During an interview at the time, the IP said she should have cleansed her hands between every glove change and worn a gown when providing care to the Resident. The IP also said she should have cleansed her hands before exiting the Resident's room. The IP said by not cleaning her hands between glove changes and prior to exiting the room or wearing a gown when touching the Resident's drainage bag, she placed the Resident at risk of getting an infection. 3. Review of the facility policy titled Catheter Irrigation, reviewed/revised 5/2/25, indicated urinary catheters may be irrigated to provide for and maintain constant urinary drainage or to administer medication. The policy also included the following: -Urinary catheters shall be irrigated by a licensed nurse using sterile technique, under the orders of the Physician. -Routine irrigation is not recommended. -Orders shall include the type and amount of irrigating solution or medication. -irrigation through a closed system is the preferred method of irrigation. -For irrigation through a drainage port: >disconnect the catheter from the drainage bag >disinfect the catheter drainage port with an antiseptic pad and allow to dry. >attach a syringe, maintaining sterility of the tip, to the drainage port. >instill the irrigating solution into the catheter as directed and then draw back on the plunger to evacuate any clot or debris. >empty the syringe into the container >continue to irrigate as directed until clear or clot free >connect a new drainage bag as directed >dispose of all used supplies in the appropriate receptacle >remove gloves and perform hand hygiene Review of Resident #12's Comprehensive Care Plan included the following: -Urinary Catheter Care Plan, initiated 3/6/22, indicated the Resident's was at increased risk of infection and complications related to catheter use. The Urinary care plan included the following interventions: >provide catheter care per policy (3/6/22) >irrigation with Normal Saline solution as ordered for when the catheter is blocked (3/6/22) Review of the Minimum Data Set (MDS) Assessment, dated 2/13/26, indicated Resident #12: -was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 14 out of a possible 15 points, -was dependent on staff for toileting needs -had an indwelling urinary catheter Review of Resident #12's May 2026 Physician's orders included the following: -Irrigate the foley catheter as needed with 30 milliliters (ml) of Normal Saline if not draining PRN (as needed) for blockage/leakage, initiated 2/9/22 -Monitor foley catheter at bedside drainage every shift that is not touching the floor and it is in the privacy bag every shift, initiated 1/15/24 -EBP related to ESBL/foley, every shift for prevention/protection, initiated 10/2/24 On 5/19/26 at 12:45 P.M., the surveyor observed Resident #12 dressed in a hospital gown and seated in a wheelchair positioned next to the bed in his/her room. The Resident's urinary drainage bag was observed positioned under the wheelchair seat and the catheter tubing with dark red urine was observed laying on the ground. On 5/19/26 at 2:12 P.M., the surveyor observed Nurse #4 complete the irrigation of Resident #12's catheter tubing as follows: -EBP signage and bin containing gown and gloves were observed outside of Resident #12's room. -Nurse #4 entered the Resident's room with supplies. Upon entering the room, Nurse #4 opened a package containing a urinary drainage bag and tubing, a bottle of sterile water and a package containing a piston syringe with a bulb top. -Nurse #4 took the piston syringe and drew up 30 ml of sterile water from the container and put the piston syringe back in the opened packaging. -Nurse #4 placed a towel under the Resident's wheelchair. The Resident's urinary drainage bag was observed under the wheelchair seat and the catheter tubing laying on the floor. -With ungloved hands, Nurse #4 inspected the urinary tubing and said the urine in the tubing was clear now. -Nurse #4 then went into the bathroom, gathered a trash receptacle, performed hand hygiene and donned a gown and gloves. -Nurse #4 disconnected the Resident's urinary drainage bag and tubing from the drainage port. Nurse #4 showed the surveyor the removed urinary drainage bag which contained dark red urinary contents and then placed the urinary drainage bag and tubing in the trash receptacle. -Nurse #4 discarded her gloves in the trash receptacle and donned new gloves without performing hand hygiene. -Nurse #4 inserted the piston syringe containing the sterile water into the Resident's catheter drainage port, informed the Resident that it was going to be cold, and then inserted the solution into the drainage port. -Resident #12 was observed to jerk and say ouch at this time and Nurse #4 asked him/her if they were okay and then continued to irrigate the catheter port with the sterile water. -Nurse #4 then removed the piston syringe and attached new tubing with the urinary drainage bag to the drainage port. Nurse #4 hung the urinary drainage bag under the Resident's wheelchair, ensured the catheter tubing remained off the floor, doffed her gown and gloves and performed hand hygiene. During an interview immediately following the procedure, Nurse #4 said prior to the irrigation procedure, Resident's catheter tubing was on the floor and should not have been because of the increased risk of infection. Nurse #4 said she should have performed hand hygiene after removing her gloves and prior to donning new gloves, but she did not. 4. Resident #14 was admitted to the facility in December 2025 with diagnoses including artificial opening status, facial weakness following Cerebral Infarction, hemiplegia and hemiparesis following Cerebral Infarction affecting left non-dominant side and dysphagia following Cerebral Infarction. Review of Resident #14's Person-Centered Care Plan indicated: -increased susceptibility for infection related to Gastrostomy Tube (G-tube- a medical device inserted into the stomach to provide nutrition and liquid nourishment directly into the stomach/intestines through a gastrointestinal feeding tube), initiated 1/19/26, -interventions for Enhanced Barrier Precautions EBP) as ordered. Review of Resident #14's Minimum Data Set (MDS) Assessment, dated 3/6/26, indicated: -was rarely/never understood and had short- and long-term memory loss.-received nutrition via a feeding tube. -received over 51 percent (%) of their calories via tube feed. -received fluid intake via a feeding tube and received over 501 cc (cubic centimeters) of fluid for hydration per day. Review of Resident #14's May 2026 Physician's orders indicated: -Enhanced Barrier Precautions (EBP) related to g-tube every shift, initiated 1/20/26. On 5/17/26 at 9:14 A.M., the surveyor observed an Enhanced Barrier Precautions sign posted outside of Resident #14's door. On 5/18/26 at 12:52 P.M., the surveyor observed two Rehabilitation Service Staff members (RSS) standing at Resident #14's bedside in his/her bedroom. RSS #1 was observed leaning on Resident #14's bed with no gown or glove in use and her clothing in contact with the Resident bed linens. RSS #1 was observed to pull the sheet covering Resident #14 and remove a beige color hand splint from the Resident's left hand. RSS #2 also had no gown or glove in use and removed a navy-blue leg brace from the Resident's left leg. RSS #1 then covered Resident #14 with a sheet and exited the room. During an interview on 5/18/26 at 12:55 P.M., RSS #1 said Resident #14 has a g-tube feed, was not on any type of precaution and does not require a gown and or gloves when providing splint and brace care and services. RSS #1 said she was removing a new splint that Resident #14 had on. RSS #1 said the EBP signage posted outside the door was not meant for Resident #14. RSS #1 also said that she did not need to wear gown and gloves when she was handling Resident #14's linens or when removing the splint and the leg brace from the Resident. During an interview on 5/19/26 at 8:20 A.M., Unit Manager (UM #1) said Resident #14 was on EBP and her expectation was that any staff member providing hands on care was required to wear a gown and gloves to prevent the transmission of infection to the Resident. During an interview on 5/20/26 at 10:55 A.M., the Assistant Director of Nursing (ADON) said that all Rehabilitation staff members had been educated on EBP during orientation. The ADON said that all staff members have an understanding on how to determine if a resident has EBP. The ADON said that staff members should look on the back of the EBP sign posted outside of all resident doors with EBP signage, and there will be an indicator of which resident was on EBP. The ADON said that Resident #14 was listed at the back of the signage that indicated an EBP was in place. The ADON said Resident #14 had an artificial opening for G-Tube and required staff to wear a gown and gloves during high contact care activities. The ADON said that when staff do not adhere to EBP when providing high contact care to Resident #14, there was an increased risk of infection as staff members could transfer infection to the Resident who had an artificial opening.

Based on observation, interview, and record review, the facility failed to provide assistance for activities of daily living (ADL) for one Resident (#3) out of a total sample of 29 Residents.Specifically, the facility failed to ensure Resident #3 was provided grooming of the fingernails when the Resident was dependent on facility staff for assistance with grooming. Findings include:Review of the facility policy Activities of Daily Living (ADLs) dated 5/16/25, indicated:-Care and services will be provided for the following activities of daily living: bathing, dressing, grooming and oral care.-A resident who is unable to carry out activities of daily living will receive the necessary services to maintain food nutrition, grooming, and personal and oral hygiene. Resident #3 was admitted to the facility in August 2022 with diagnoses including neurocognitive disorder with lewy bodies, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, other secondary parkinsonism. Review of Resident #3's Comprehensive Care Plan for ADL's, initiated 8/4/22 and revised 2/6/24, indicated:-assist to total dependence when fatigued for grooming. Review of Resident #3's Minimum Data Set (MDS) Assessment, dated 4/24/26 indicated the Resident:-was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of seven out of a total possible score of 15.-required substantial to maximal assist with personal hygiene.-had not demonstrated any refusal of care. Review of Resident #3's Resident Care Card indicated Resident #3 required substantial/maximal assistance with personal hygiene (grooming). On 5/17/26 at 9:09 A.M., the surveyor observed Resident #3's nails on the left hand were untrimmed and extended past the nail bed and had brown debris under the nails from the free edge of the nail to the nail tip. The surveyor was unable to view the Resident's right hand fingernails as his/her right hand was closed in a loose fist and he/she was unable to open the right hand. During an interview at the time, Resident #3 was unable to answer about when/or if he/she would like their fingernails to be trimmed. On 5/18/26 at 10:18 A.M., the surveyor observed Resident #3's fingernails on both the left and right hand were untrimmed and all the fingernails had brown and black debris underneath the fingernails from the free edge of the nail to the nail tip. During an interview on 5/18/26 at 11:12 A.M., Certified Nurse Aide (CNA) #9 said the CNA's have a Care Kardex in a binder that they look at to see what kind of care the residents need and how much help they need. CNA #9 said grooming tasks like hair, nails and shaving would be completed as needed during daily ADL care. During an interview on 5/18/26 at 2:21 P.M., CNA #5 said that grooming tasks including nail cleaning and trimming should be done daily. CNA #5 said the CNA's know how much assistance a resident requires to complete grooming tasks from the Care Kardex binder on the unit or they can look in the computer. CNA #5 said resident care is documented daily in the computer, including if the resident refuses to allow the CNAs to complete any care. On 5/19/26 at 11:37 A.M., the surveyor and Unit Manager (UM) #2 observed Resident #3's fingernails. The Resident's fingernails on both hands remained untrimmed and had brown and black debris under all the fingernails. UM #2 said that Resident #3's fingernails should have been cleaned and trimmed. UM #2 said the expectation is nail care should be done with daily ADL care and if the resident is refusing to allow CNA staff to complete nail care, the CNA's should be reporting this to nursing.

Based on records reviewed and interviews, for two of three sampled residents, (Resident #1 and Resident #2), the Facility failed to ensure they maintained complete and accurate medical records, when their Certified Nurse Aide (CNA) Activities of Daily Living (ADL) Flow Sheets were incomplete.Findings include:Review of the facility policy titled, POC (point of care) Documentation Skill Sheet, dated 10/27/23, indicated:-You must chart every time you give care to a resident-You must complete all charting before leaving-If it's not documented, it means it was not doneResident #1 was admitted to the Facility in March 2026, diagnoses included acute and chronic respiratory failure with hypoxia (low oxygen), urinary tract infection, pneumonia, and orthostatic hypotension (sudden drop in blood pressure when standing up).Review of Resident #1's Minimum Data Set (MDS) Assessment, dated 04/06/26 indicated he/she required various levels of staff assistance with his/her Activities of Daily Living (ADLs) including but not limited to bathing, dressing, grooming, transfer, toileting and personal hygiene.Review of Resident #1's ADL Flow Sheets (CNA documentation) dated 04/01/26 through 04/13/26 indicated that for the following shifts, documentation on the flow sheets was incomplete:-7:00 A.M. to 3:00 P.M. 9 days (out of 13 days) all ADL care areas were left blank.-3:00 P.M. to 11:00 P.M. 3 days (out of 13) all ADL care areas were left blank.-11:00 P.M. to 7:00 A.M. 2 (out of 13) all ADL care areas were left blank. Resident #2 was admitted to the Facility in September 2023, diagnoses included vascular dementia, hypertension, and depression.Review of Resident #2's MDS assessment dated [DATE] indicated he/she required various levels of staff assistance with his/her ADLs including but not limited to bathing, dressing, grooming, transfer, toileting and personal hygiene.Review of Resident #2's CNA Flow Sheet for the Month of April 2026 indicated that for the following shifts, documentation on the flow sheet was incomplete: -7:00 A.M. to 3:00 P.M.-16 days (out of 30 days) all ADL care areas were left blank.-3:00 P.M. to 11:00 P.M.-2 (out of 30 days) all ADL care areas were left blank.-11:00 A.M., to 7:00 A.M.- 4 (out of 30 days) all ADL care areas were left blank.During an interview on 05/12/26 at 3:05 P.M., CNA #2 said CNAs are responsible for documenting care every shift.During an interview on 05/12/26 at 4:40 P.M., the Director of Nursing said CNAs should document care every shift, but she realized that there had been omissions in documentation.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who required medication to treat hypotension (low blood pressure) and had a Physician's order to hold (not administer) the medication for a systolic blood pressure (SBP-top number, represents the pressure in arteries when the heart contracts) greater than 120, the Facility failed to ensure the resident was free from significant medication errors when he/she was administered the medication outside of the prescribed parameter, placing him/her at risk for high blood pressure.Findings include:Review of the Facility policy titled, Oral Medication Administration, revised 2024, indicated Facility staff should:-Review and confirm medication orders for each individual resident on the Medication Administration Record (MAR) prior to administering medications to each resident.-Review the MAR for any tests or vital signs that need to be determined prior to preparing the medication.-Obtain and record any vital signs or other monitoring parameters ordered or deemed necessary prior to mediation administration.Resident #1 was admitted to the Facility in March 2026, diagnoses included acute and chronic respiratory failure with hypoxia (low oxygen), urinary tract infection, pneumonia, and orthostatic hypotension (sudden drop in blood pressure when standing up).Review of Resident #1's Physicians' Orders for April 2026, indicated it included an order for, but not limited to the following:Midodrine HCL (medication used to treat low blood pressure) oral tablet 10 milligrams (mg), give one tablet by mouth in the morning and one tablet by mouth in the afternoon related to orthostatic hypotension (low blood pressure). Hold (do not give) for SBP (systolic blood pressure) greater than 120, start date 04/03/26. Review of Resident #1's Medication Administration Record (MAR) for April 2026, indicated he/she was administered Midodrine HCL 10 mg by nursing, despite having (per nursing documentation) a systolic blood pressure reading that was greater than 120, (and therefore per MD orders it should have been held) on the following dates/times:04/11/26 morning dose (between 8A.M. and 10A.M.)-BP 128/72 04/11/26 afternoon dose (scheduled between 12P.M. and 2 P.M.)-BP 129/69During an interview on 05/12/26 at 4:00 P.M., Nurse #3 said that she had administered Midodrine to Resident #1 on 04/11/26 in the morning (between the hours of 8:00 A.M. and 10:00 A.M.), and again the same day in the afternoon (between the hours of 12:00 P.M. and 2:00P.M.). The surveyor and Nurse #3 reviewed Resident #1's blood pressure documentation for 04/11/26 (morning-128/72 and afternoon-129/69) and Nurse #3 said she should not have administered Midodrine to Resident #1 because Resident #1's SBP's were greater than 120, both in the morning and in the afternoon.During a telephone interview on 05/13/26 at 9:50 A.M., the Nurse Practitioner said that she expected the facility nurses to check Resident #1's blood pressure each time prior to administering Midodrine and to hold the Midodrine if his/her SBP was greater than 120. The NP said Resident #1 should not have received Midodrine on 4/11/26, when his/her SBP was over 120.During an interview on 05/12/26 at 4:40 P.M., the Director of Nursing (DON) said her expectation for medication administration is that nurses read and follow the Physicians' orders on the Medication Administration Record. The DON said Nurse #3 should not have administered Midodrine to Resident #1 in the morning and afternoon of 04/11/26 when his/her SBP was documented above 120, and therefore resulted in medication errors.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1) who was found to have an injury (new bruise), the Facility failed to ensure he/she was provided with quality of care and services in accordance with his/her comprehensive person-centered plan of care, when although the facility was unable to determine exactly when or how the injury occurred, as a result of their investigation it was determined that gait belts were not consistently being used by staff during transfers, in accordance with facility policy, therefore placing Resident #1 and other residents at risk for potential injury. Findings include:Review of the Facility Policy titled, Gait Belt Use, dated April 2025, indicated gait belts must be used when physically transferring or ambulating residents.Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 01/23/26, indicated Resident #1 had sustained a fracture. The Report indicated the fracture was likely sustained during a transfer from chair to bed.Resident #1 was admitted to the Facility February 2022, with diagnoses including vascular dementia, hypertension (high blood pressure), hypothyroidism (low thyroid hormone) repeated falls and difficulty walking.Review of Resident #1's Minimum Data Set (MDS) Assessment, dated 01/09/26, indicated he/she had short-term and long-term memory problems, and was dependent on staff for activities of daily living (eating, dressing, bathing, toileting, and transferring).Review of Resident #1's Certified Nurse Aide (CNA) Care Card (used by CNAs to determine individual resident care needs), indicated he/she was dependent on staff assistance for transfers from chair to bed and bed-to chair.Review of Resident #1's Impaired Functional Mobility care plan, reviewed and renewed with his/her 01/09/26 MDS, indicated he/she required assistance of one staff, or two staff when fatigued, to move from a lying position to sitting on the edge of the bed, to be positioned in the chair, to be positioned in bed, and to ambulate with a walker.Review of Nurse Progress Note, dated 01/17/26, indicated Resident #1 had a fracture of the distal right femoral metaphysis (lower end of the thigh bone).Review Resident #1's Mobile X-ray report, dated 01/17/26, indicated an acute distal right femoral metaphysis fracture.During an interview on 02/10/26 at 1:45 P.M., the Assistant Director of Nurses said that on the morning of 01/16/26, nursing staff requested that she look at a bruise on Resident #1's right knee. The Assistant Director of Nurses said she assessed Resident #1, found his/her knee to be bruised and swollen, notified the Nurse Practitioner and obtained an order for an x-ray. The Assistant Director of Nurses said she had been responsible for investigating Resident #1's injury and determined that the injury most likely occurred during a transfer.During an interview on 02/10/26 at 3:00 P.M., CNA #3 said that he had noticed the bruise on Resident #1's leg while he was dressing him/her on the morning of 01/16/26. CNA #3 said he did not transfer Resident #1 that day but said that he had transferred Resident #1's on previous days by lifting him/her from the bed with another CNA without using a gait belt.During a telephone interview on 02/11/26 at 3:00 P.M., CNA #5 said that she had assisted CNA #3 to stand-pivot transfer Resident #1 on previous days, and that they had transferred him/her without the use of a gait belt. During an interview on 02/10/26 at 2:30 P.M., CNA #2 said she and another CNA (could not provide name or identify) had transferred Resident #1 from his/her wheelchair to bed in the afternoon on 01/15/26. CNA #2 said that they had lifted Resident #1 from the wheelchair and pivoted him/her to the bed and did so without using a gait belt. CNA #2 said nothing unusual had occurred during the transfer and that Resident #1 showed no changes in behavior or signs of pain during the transfer or afterwards while she was providing care. CNA #2 said they should have used a gait belt to transfer Resident #1 but that they had not.The Assistant Director of Nurses said she had determined that the last time Resident #1 was transferred, prior to staff noticing a bruise on his/her knee, was on 01/15/26 when he/she was transferred from his/her wheelchair back into bed in the afternoon. The Assistant Director of Nurses said during her investigation she had spoken with staff who had told her that a gait belt had not been used during Resident #1's transfer from wheelchair to bed in the afternoon on 01/15/26. The Assistant Director of Nurses said it was the Facility policy to use a gait belt when physically transferring or ambulating residents and that staff should have used a gait belt for Resident #1's transfer to bed in the afternoon on 01/15/26, but that they had not.On 02/10/26, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction, with an effective date of 02/04/26, which addressed the area of concern as evidenced by:A. Resident #1 no longer resides at the Facility.B. On 1/19/26, Administrative staff ensured that gait belts were available and accessible on all nursing units.C. On 1/26/26 the Assistant Director of Nurses and/or designee completed a house wide audit of residents who required assistance with transfers and ambulation to determine if staff were using gait belts according to Facility policy.D. On 02/2/26 the Director of Nurses and/or designee initiated ongoing audits (which included observations) of gait belt use by staff during resident transfers and ambulation. Audits (random observations) will continue weekly for four weeks, then monthly for three months.E. On 02/04/25, the Director of Nurses, Assistant Director of Nurses and Staff Development Coordinator (SDC) completed training for Nurses and CNAs on the use of gait belts for resident transfer and ambulation, which included a review of Facility policy.F. The concern for gait belt use during resident transfers and ambulation was discussed by the Quality Assurance Performance Improvement Committee (QAPI) on 01/28/26, ongoing audit result will be submitted to QAPI committee monthly for three months to ensure compliance.G. The Director of Nurses and/or designee are responsible for overall compliance.

Based on observations, interviews, and record reviews, the facility failed to provide sufficient nursing staff on two resident Units (Lake Unit and Tapestry Unit) out of three resident units, to attain/maintain the highest physical, mental, and psychosocial well-being of each resident. Specifically, the facility failed to: -Provide sufficient nursing staff to ensure all residents on the Lake Unit, including Resident #119, were provided with timely morning activity of daily living (ADL) care. -Provide sufficient nursing staff to ensure all residents on the Lake and Tapestry Units were provided timely medication administration. Findings include: Review of the Facility Assessment, last reviewed 3/26/25, indicated the following: -The facility's capacity was 135 with an average daily census of 124.87 residents. -For bathing, the facility had an average of 79 residents requiring assistance of one to two staff and an average of 35 residents who were dependent on staff. -For dressing, the facility had an average of 86 residents requiring assistance of one to two staff and an average of 24 residents who were dependent on staff. -For transfers, the facility had an average of 84 residents requiring assistance of one to two staff and an average of 14 residents who were dependent on staff. -For toileting, the facility had an average of 74 residents requiring assistance of one to two staff and an average of 29 residents who were dependent on staff. -ADL care included: bathing/showers, mouth care, dressing, eating . -Mobility care included: transfers, ambulation . -Mental health and behavior care included: .identify and implement interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment, . -Medication care included: administration of medications that residents need. -The facility utilized a staffing calculator based on daily census to provide safe staffing ratios. -For staffing, the facility would take into consideration resident acuity and need to the extent possible. Review of the facility's Lake Unit Midnight Census Report, dated 4/6/25 (indicating the census for 4/7/25) indicated there were 42 residents actively residing on the Lake Unit. Review of the facility's Nursing Staff Schedule for 4/7/25 indicated the following: -The total required number of Certified Nurse Aides (CNAs) for the day (7:00 A.M.-3:00 P.M.) shift =14.0. -The total number of assigned CNAs for the day shift =11.1. -Three CNAs were assigned to work on the Lake Unit for the day shift. -The total required number of Licensed Nurses for the day shift = 6.0. -The total number of assigned Licensed Nurses for the day shift = 6.0 (two Nurses were assigned to the Lake Unit). -The total number of Resident Care Assistants required for 8:00 A.M. through 4:00 P.M. = 1.0. -The total number of Resident Care Assistants assigned for 8:00 A.M. through 4:00 P.M. = 0.0. 1. Resident #119 was admitted to the facility in March 2025 with diagnoses including history of Traumatic Brain Injury (TBI), Dementia, Dysphagia, and weakness. On 4/7/25, between 8:40 A.M. and 9:33 A.M., surveyor #2 observed the following from outside of Resident #119's room: -Resident #119 was lying in bed with the head of the bed slightly elevated and his/her eyes closed. -At 8:54 A.M., a CNA entered Resident #119's room with the Resident's breakfast tray. -The CNA placed the breakfast tray on a table at the foot of the bed, stated the Resident's name, then entered the bathroom to wash her hands and exited the room. -A different CNA (#1) entered the Resident #119's room at 9:26 A.M. (32 minutes after the Resident's breakfast tray was delivered to the Resident's room) at which time CNA #1 woke and repositioned the Resident, then began assisting the Resident to eat. -CNA #1 exited the room at 9:33 A.M. (seven minutes after initiating feeding assistance for Resident #119) carrying the Resident's breakfast tray. -The Resident remained in bed with his/her head elevated and was observed to be chewing the food that was in his/her mouth. During an interview at the time, CNA #1 said that Resident #119 had eaten his/her oatmeal and consumed approximately half of his/her milk, and did not consume any of the main breakfast entree. During an interview on 4/7/25 at 10:12 A.M., with surveyor #2 and Nurse #2, Nurse #2 said the day shift began with two CNAs to care for 45 residents (45 was the Unit's capacity; census on the Unit was 42) and that the third CNA assigned for the day shift did not start working on the Unit until about 7:30 A.M. Nurse #2 said she felt bad that the CNAs did not have enough time to feed the Residents. Nurse #2 said Resident #119 was a slow eater but always ate all of his/her meals. Nurse #2 said if the staff had enough time, Resident #119 would have eaten all of his/her breakfast. During an interview on 4/7/25 at 10:21 A.M., with surveyor #2 and CNA #1, CNA #1 said there were three CNAs scheduled to work on the Lake Unit. CNA #1 further said at this time she still had five residents to provide morning ADL care to and two residents to provide showers for. On 4/7/25 at 12:04 P.M., surveyor #1 observed Resident #119 lying in bed with the head of the bed elevated and the Resident's eyes were open. During an interview on 4/7/25 at 12:15 P.M., with surveyor #1 and Nurse #7, Nurse #7 said that she was the supervisor on the Lake Unit. Nurse #7 said some residents were still in bed and that staff were running a bit behind. Nurse #7 said it was a busy day, and she did not know if any staff had called out of work that day. On 4/7/25, between 12:16 P.M. and 1:14 P.M., surveyor #1 observed the following from outside of Resident #119's room: -Two staff members entered Resident #119's room and closed the door. -Staff opened the Resident's door at 12:19 P.M. and the surveyor observed that Resident #119 was sitting up in his/her wheelchair. -The Resident was wearing a hospital gown with ties in the back that were not tied. -The back of the Resident's hospital gown was open, and the Resident's upper back was exposed. -One staff member assisted Resident #119 down the hallway toward the Dining Room. -The Resident was served his/her lunch meal at 12:31 P.M. and CNA #10 began assisting Resident #119 to eat at 12:34 P.M. -At 12:53 P.M., while Resident #119 was still eating, CNA #10 stood up and said she would be right back. -CNA #10 proceeded to leave the Dining Room. -At 12:56 P.M., CNA #1 sat next to Resident #119 and assisted the Resident with eating. CNA #10 had not returned. -The surveyor observed CNA #10 entering and exiting resident rooms in the hallway closest to the Dining room, carrying resident meal trays and placing them back into the meal cart. -At 1:06 P.M., CNA #1 stopped assisting Resident #119 to eat and attended to another resident in the Dining room. -At 1:07 P.M. another staff member sat next to Resident #119 and assisted the Resident with eating. -The Resident finished eating at 1:14 P.M. During an interview on 4/7/25 at 1:15 P.M., with surveyor #1 and CNA #1, CNA #1 said there were three CNAs working on the Lake Unit that day on the 7:00 A.M. through 3:00 P.M. (day) shift. CNA #1 said they were supposed to be staffed with four CNAs for the day shift on the Unit and that when they were staffed with three CNAs, the CNAs were unable to complete resident morning ADL care timely. CNA #1 said there were several residents who required assistance of two staff for transfers and several residents who required assistance for bathing and dressing. CNA #1 said if there had been another CNA on the Unit, all morning ADL care would have been provided for the residents by 11:00 A.M., and the residents would have been out of bed before lunch. CNA #1 said she still had one resident remaining to assist with showering. CNA #1 said she normally would have completed the shower for the resident before lunch, and that because only three CNAs were working, she was not able to provide the resident's shower in the morning. CNA #1 said all ended up working out because the resident who still needed a shower did not feel well in the morning, and he/she was agreeable to shower later in the day. CNA #1 said the CNAs on the Lake Unit also had responsibilities for answering the call lights timely, providing drinks, snacks, and toileting assistance for residents as well as assisting residents who smoke to the smoking area. CNA #1 said that late morning care provided to residents, including Resident #119, was not due to preferences of the residents and that it was due to having three CNAs to care for 42 residents. During an interview on 4/10/25 at 9:33 A.M.,with surveyor #1 and the Scheduler, the Scheduler said that the facility uses a staffing calculator to determine nursing staff levels and that resident acuity is not cnsidered when determining staffing needs. The Scheduler said the numbers on the schedule indicated as required were for the whole facility and not separated by unit. The Scheduler said it was the facility's responsibility to determine how to distribute the staff within the facility. The Scheduler said there were CNA callouts for the day shift on 4/7/25, and that one of the callouts came in the evening before (4/6/25). When surveyor #1 asked how the facility attempted to fill the CNA callout spots, the Scheduler said she messaged two CNAs in the morning on 4/7/25 and she thought the supervising Nurse who worked the prior evening had made some calls. The Scheduler said she did not have time to contact any other staff in the morning on 4/7/25 because she was pulled to work as a CNA on the Tapestry Unit from 8:00 A.M. until 9:00 A.M. The Scheduler said she would need to contact the supervising Nurse who took the CNA callout on 4/6/25 for the 4/7/25 day shift to see whether the Nurse made attempts to contact other staff to come in and work. The Scheduler also said the three CNAs assigned to work on the Lake Unit had punched in on time, so she did not understand why the Lake Unit would only have had two CNAs working at the start of the day shift on 4/7/25. At the time, surveyor #1 and the Scheduler reviewed the daily nursing staff schedule for 4/7/25 as follows: -CNAs required: 14.0 -CNAs assigned: 11.1. During a follow-up interview on 4/10/25 at 10:48 A.M., with surveyor #1 and the Scheduler, the Scheduler said that the supervising Nurse did not attempt to contact any staff to fill the CNA callout received for the 4/7/25 day shift. The Scheduler also said she found out that CNA #1, who was assigned to work on the Lake Unit for the day shift on 4/7/25, punched in on time that day but did not arrive on the Lake Unit until about 7:20 A.M. which was why the Lake Unit only had two CNAs at the start of the day shift on 4/7/25. During an interview on 4/10/25 at 11:09 A.M., with surveyor #1 and the Director of Nursing (DON), the DON said that the Lake Unit was very busy. The DON said the Lake Unit was usually staffed with three CNAs on the day shift and if there was a need, a fourth CNA would be assigned by pulling a CNA from another Unit. The DON said she had not heard of any issues that indicated nursing staff were not able to get their work done timely on the Lake Unit when staffed with three CNAs. The DON said the facility had a large per diem CNA pool and that the Scheduler would have been responsible to place calls on 4/7/25 in an attempt to get staff to come in and fill the spots where CNAs had called out. The DON said there was a Resident Care Assistant (RCCA) assigned to work the day shift on the Lake Unit, but the RCCA was also out. The DON said she was not aware the RCCA was not working on 4/7/25 until about 11:00 A.M. The DON said acuity of the residents is considered when determining where to place assigned staff and if staff on the Lake Unit had communicated they were having difficulty getting their work done on 4/7/25, this would have been addressed so that the residents' needs could be met. 47901 2. On 4/7/25 at 10:12 A.M., during a medication administration observation of Nurse #2 on the Lake Unit, surveyor #2 observed the following: -Nurse #2 stopped the medication administration process and toileted residents. -Nurse #2 stopped the medication administration (twice), answered resident call lights, and provided care as needed. During an interview at the time, surveyor #2 asked Nurse #2 why most of the residents medication administration screens were Red and Nurse #2 said that she was very late with the resident medication administration. Nurse #2 said she had to stop the medication administration to deliver breakfast trays, assist with feeding the residents, assist the CNAs to answer call lights, and toilet the residents as needed. Nurse #2 said they had started the shift with two CNAs for 45 Residents on the Lake Unit (capacity of the Unit was 45, census on the Unit was 42, with mixed rehab and long-term care residents). Nurse #2 said the third CNA assigned to work the day shift did not show up on the Unit until about 7:30 A.M. Nurse #2 said she still had five residents who had morning medications to be administered and they were all late. On 4/7/25 at 10:48 A.M., during a medication administration observation of Nurse #4 on the Tapestry Unit Side One by surveyor #2, Nurse #4 said that she was very late with the medication administration. Nurse #4 said the Tapestry Unit had been very busy with delivering breakfast trays, assisting residents to eat, and constantly redirecting wandering residents to ensure the residents' safety. Nurse #4 said there were two Nurses on the Tapestry Unit with four CNAs, but the intermittent redirection of residents caused a delay in the medication administration. Nurse #4 said she had eight residents waiting to receive their morning medications that were due at 9:00 A.M. On 4/7/25 at 11:09 A.M., during a medication administration observation of Nurse #3 on the Tapestry Unit, Side Two by surveyor #2, Nurse #3 said that she had two residents waiting to receive their 9:00 A.M. medications. Nurse #3 said it was very difficult to complete medication administration timely due to the required, frequent redirection of residents. Nurse #3 said the Nurses had to stop medication administration to assist with feeding residents. Nurse #3 said one Nurse and two CNAs had to stay in the dining room to monitor breakfast safety while the other Nurse and two CNAs remained on the floor to assist the other residents who were eating in their bedrooms and redirect wandering residents for safety. During an interview on 4/7/25 at 2:05 P.M., with surveyor #2 and the Director of Nursing (DON), the DON said that she was aware that sometimes the residents' behaviors could cause a delay in the medication administration and that the Corporation was auditing the medication administration to liberalize the times of the medication administration. The DON said nursing department staffing is based on the residents' ratios and the facility Scheduler managed the staffing ratios. The DON further said she knew two CNAs had called out for the morning shift on the Tapestry Unit but was unaware if attempts had been made to replace the two CNA call outs. During an interview on 4/7/25 at 3:11 P.M., the Scheduler said she worked as CNA sometimes when there was a need to do so. The Scheduler said two CNAs had called out for the morning shift on the Tapestry Unit, and that she needed to assist on the Tapestry Unit as a fourth CNA for one hour until one CNA arrived on the Tapestry Unit at 8:00 A.M. The Scheduler said she did not have time to call other staff members to see if they could come in and work. The Scheduler said she was unaware that the third CNA assigned to the Lake Unit did not arrive on the Lake Unit until 7:30 A.M.

Based on observation, interviews, and record reviews, the facility failed to serve food that was palatable, and at a safe and appetizing temperature on one Unit ([NAME] Unit) out of three units observed. Findings include: During the initial screening process on 4/6/25 the following comments were made by Residents relative to the food served at the facility: -Hot food is always cold. Staff do not offer to reheat the food. -Hot food is never hot, it is always cold. Staff do offer to warm it up in microwave but then everything is over cooked. -Hot food is cold by the time it is served to him/her in his/her room. -Hot food comes lukewarm at times but is most often cold. -Never get hot meals. -Food comes lukewarm. During the Resident Council meeting held on 4/7/25 from 11:00 A.M. to 11:50 A.M., 12 of the 24 Resident's in attendance said the hot food served at the facility is often served cold. Review of the 1/28/25 Resident Council Meeting minutes indicated the Residents expressed food was cold. Review of the Resident Council Concern Follow-Up, dated 2/28/25, indicated the Food Services Directors' (FSD) response to the 1/28/25 concern of the food being cold: Cooks temp food before we start serving. On 4/8/25 at 9:18 A.M., the surveyor completed a test tray during the breakfast meal on the [NAME] Unit with the Regional FSD and the following temperatures and palatability was observed: -French toast 96.2 degrees Fahrenheit (F), cold to taste -Scrambled eggs 95.1 F, cold to taste -Sausage link 97.6 F, cold to taste -Ground sausage 94 F, cold to taste -Puree sausage 97.7 F, cold to taste During an interview following the test tray observation, the Regional FSD said food should be palatable and at an appetizing temperature when it is served. The Regional FSD said he would expect hot food temperatures to be higher than what they were served at today. During an interview on 4/8/25 at 9:27 A.M., Nurse #1 said many residents in the facility complain regularly that the hot food is served cold and often times staff have to reheat the food in the unit microwave. During an interview on 4/8/25 at 1:17 P.M., the FSD said she was aware there have been concerns from the Residents in the past relative to cold food and she had done test trays but would need to look for the documentation. The FSD said food should be served a palatable temperature, hot food should be hot and cold food should be cold. The FSD said hot food does not leave the kitchen under 165 Fahrenheit (F) and the temperature should not fall significantly by the time the food reaches the units. During a follow-up interview on 4/8/25 at 2:22 P.M., the FSD provided documentation from one test tray completed for each meal on the Tapestry Unit on 8/6/24 and two test trays completed for the breakfast meal on the Tapestry Unit on 1/22/25. The FSD was unable to provide any documentation to show test trays had been done on the [NAME] Unit or that any test trays had been done after the Resident Council had voiced concerns about cold food during the 1/28/25 Resident Council Meeting. The FSD said one day of test trays in August 2024 and one day of test trays in January 2025 was not sufficient and test trays should have been on going to assess the reasons why food was being delivered cold to the units.

Based on record reviews, and interviews, the facility failed to ensure that Pneumococcal immunizations were offered and administered for two Residents (#12 and #20) of five applicable residents, out of a total sample of 26 residents. Specifically, the facility failed to: 1. Offer Pneumococcal immunization for Resident #12 when the Resident had been previously immunized and was not up-to-date with Pneumococcal immunization, which increased the Resident's risk for Pneumococcal disease. 2. Administer Pneumococcal immunization for Resident #20 when the Resident had been previously immunized, was not up-to-date with the Pneumococcal immunization, and consented to Pneumococcal immunization, which increased the Resident's risk for Pneumococcal disease. 3. Offer and administer Pneumococcal immunizations for each resident who was eligible for, and not up to date with Pneumococcal immunization, which increased each resident's risk for Pneumococcal disease. Findings include: Review of the facility policy titled Procedure of Pneumococcal Vaccination of Residents indicated the following: -Over age 50, prior vaccination received one dose of PCV13: recommend pneumococcal vaccine 1 dose of PCV20 or 1 dose of PCV21 at least 1 year after the last PCV13 dose. Review of the CDC guidance titled Pneumococcal Vaccine Recommendations, dated 10/26/24, indicated the following for individuals [AGE] years of age and older: -Administer PCV (Pneumococcal Conjugate Vaccine) 15 (Pneumococcal immunization that protects against 15 types of Pneumococcal disease), PCV20 (Pneumococcal immunization that protects against 20 types of Pneumococcal disease), or PCV21 (Pneumococcal immunization that protects against 21 types of Pneumococcal disease), for all adults [AGE] years or older: -Who have never received any Pneumococcal Conjugate Vaccine. -Whose previous vaccination history is unknown. -If PCV13 only has been administered, administer PCV20 or PCV21 at least one year later. -If PCV15 is used, administer a dose of PPSV23 at least one year later. -The minimum interval is 8 weeks and can be considered in adults with an immunocompromising condition. -If PCV20 or PCV21 is used, a dose of PPSV23 is not indicated. 1. Resident #12 was admitted to the facility in January 2023 and was over the age of 50. Review of Resident #12's Resident Admission Vaccination Education Form, dated 1/11/23, failed to indicate documentation the Resident and/or Resident Representative had been offered a pneumonia vaccine, educated and provided with written information on the risks and benefits of the pneumonia vaccine, or if they consented or declined to have/update their pneumonia vaccinations. Review of the Massachusetts Immunization Information Sheet (MIIS) for Resident #12 provided by the facility indicated the following: -Resident #12 received the pneumococcal conjugate vaccine (PCV) 13 on 9/22/17. -Resident #12 received an unspecified Pneumococcal vaccine on 8/3/09. During an interview on 4/9/25 at 11:30 A.M., the Director of Nursing (DON) said pneumonia vaccination and education should have been offered at the time the Resident was admitted to the facility and she would need to look and see if Resident #12 was eligible and if so if he/she had been offered pneumococcal vaccination at the time he/she was admitted to the facility. During a follow-up interview on 4/9/25 at 12:21 P.M., the DON said Resident #12 was not up-to-date on the current recommended pneumonia vaccination and she was unable to find any documentation the Resident and/or Resident Representative was offered an updated pneumonia vaccine since being admitted to the facility. 42761 2. Resident #20 was admitted to the facility in February 2023 and was greater than [AGE] years of age. Review of Resident #20's clinical record indicated the following: -The Resident received one dose of PCV13 on 5/10/11. -A signed consent dated 10/2/24, for the Resident to receive the PCV20. Further review of Resident #20's clinical record failed to indicate any evidence the PCV20 immunization had been administered to the Resident or that the immunization was medically contraindicated for the Resident. 3. Review of the facility's Resident Pneumococcal Vaccine Initial Audit, printed 4/9/25, indicated the following: -A total of 75 residents in the facility eligible for Pneumococcal immunization were not up-to-date with Pneumococcal immunization. -Updated Pneumococcal immunizations had not yet been offered to the 75 residents. During an interview on 4/9/25 at 2:50 P.M., the Infection Preventionist (IP) in Training said that she was newly hired into the Infection Prevention role at the facility and that the designated IP was providing her with training for the position. The IP in Training said that there was no tracking in place relative to resident Pneumococcal immunizations when she started working in Infection Prevention at the facility, so she and the IP completed an audit of all residents' Pneumococcal immunization status and eligibility on 3/28/25. The IP in Training said Resident #20 was not up-to-date for Pneumococcal immunization and had consented to receive the Pneumococcal immunization, but an updated Pneumococcal immunization had not been administered for the Resident. The IP in Training also said the facility did have some supply of Pneumococcal immunization available for administration to residents. The IP in Training further said the facility had not yet offered any of the residents identified as not up-to-date for the Pneumococcal immunization on the Resident Pneumococcal Vaccine Audit with an updated Pneumococcal immunization.

Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, the facility failed to: -Maintain meal carts and coffee carts in a sanitary manner for meal service for residents. -Maintain the plate warmer in a clean and sanitary manner prior to housing plates in the plate warmer for meal service to residents. -Prepare coffee for residents in a sanitary manner. -Maintain the stand-up refrigerator and stand-up freezer in a clean and sanitary manner for food storage. Findings include: Review of the facility's Dietary Department Guidelines, dated January 2014, indicated the following: -The facility must store, prepare, and distribute food under sanitary conditions. -The Dietary Department will be maintained in a clean and sanitary manner to prevent food borne illness. -All areas of the Dietary Department will be cleaned on a regular schedule. -Logs/schedules will be kept of cleaning tasks as they are completed. On 4/6/25 between 7:20 A.M. and 8:00 A.M., the surveyor observed the following in the facility's Main Kitchen: -The meal carts were lined up with their doors open in the food service area. -The meal carts contained resident trays for breakfast including the residents' meal cards, napkins, and silverware. -The inside and outside walls and the floor of each meal cart had spattered, dried, white and brown debris. -Dietary Staff #1 filled two large, insulated, spouted beverage containers with coffee from the countertop coffee maker while the large, insulated, spotted beverage containers were on the floor. During an interview at the time, Dietary Aide #1 said he was filling the coffee containers for the residents' breakfast. -Two stacked milk crates covered with spattered, dried white, tan, and brown debris were positioned on the floor between the two large, insulated, spouted beverage containers while the container was being filled with coffee. -The openings of the spouts were positioned just above the floor. -A rolling two-shelf cart containing one crumpled surgical mask, one foam cup with a cover and straw that contained some liquid, and a meal tray containing partially eaten food items was next to the coffee station. -The plate warmer was on and held two separate stacks of plates in the food preparation area. -The top of the plate warmer had several areas white, tan, and brown debris. Some of the debris resembled food crumbs. -The stand-up refrigerator and stand-up freezer contained items for resident consumption and had spattered white and brown debris on the floors, inside walls, and outside doors. -The tray line began. On 4/6/25 at 8:09 A.M., the surveyor observed the first breakfast meal cart and three-shelf coffee cart on the Lake Unit as follows: -The breakfast meal cart contained resident meal trays. -The inside and outside walls and the floor of the meal cart had spattered, dried, white and brown debris. -The coffee cart held one large, insulated, spouted beverage container of coffee, a tray of coffee mugs, a container of hot water, packets of creamer, and packets of sugar. -The shelves and handle of the coffee cart had spattered, dripped, dried white and brown debris. -Staff served the residents their meals and hot drinks from the lunch meal cart and coffee cart. On 4/7/25 at 12:03 P.M., the surveyor observed the first lunch meal cart and a three-shelf coffee cart delivered to the Lake Unit from the facility Main Kitchen as follows: -The lunch meal cart contained resident meal trays. -The inside and outside walls and the floor of the meal cart still had spattered, dried, white and brown debris. -The coffee cart held one large, insulated, spouted beverage container of coffee, a tray of coffee mugs, a container of hot water, packets of creamer, and packets of sugar. -The shelves and handle of the coffee cart had spattered, dripped, dried white and brown debris. -Staff served the residents their meals and hot drinks from the lunch meal cart and coffee cart. On 4/7/25 at 12:24 P.M., the surveyor observed the second lunch meal cart on the Lake Unit, outside of the Lake Unit Dining Room. The Resident meal trays were being passed, and the meal cart was observed to have spattered, dried, white and brown debris on the inside walls, floor, and outside walls of the cart. During an interview on 4/7/25 at 3:00 P.M., with the Food Service Director (FSD) and Regional FSD, the FSD said there was no established cleaning schedule for items in the Main Kitchen and there were no logs maintained to indicate when cleaning in the Main Kitchen occurred. The FSD said the meal carts were supposed to be cleaned between meal services and as needed and that resident meals should not be stored in and served from meal carts that are not clean. The FSD said the stand-up refrigerator and freezer should not have spattered debris inside of them, where resident food is stored. The FSD also said the two-shelf cart containing a meal tray from a previous meal, surgical mask and foam cup should not have been in the Main Kitchen where the coffee was being made and that the cart should have been brought directly into the Dish Room. The FSD also said the plate warmer should not have had dried debris and crumbs on it while storing clean plates for resident use. The FSD said the two stacked milk crates in the coffee making area were there for dietary staff to place the two large, insulated, spouted beverage containers on while transferring coffee from the coffee maker into the container. The FSD said the purpose of the milk crates was to keep the beverage containers off the floor. The FSD said there was no evidence relative to when food storage and distribution items in the Main Kitchen were last cleaned and the Regional FSD said a cleaning schedule would need to be developed.

Based on observations, interviews, and record reviews, the facility failed to maintain a clean and homelike environment for two Residents (#38 and #86), out of a total sample size of 26 residents, and for one Unit ([NAME] Unit), out of three units observed. Specifically, 1. For Resident #38, the facility staff failed to maintain the Resident's wheelchair in a clean and sanitary manner when the Resident was dependent on the wheelchair use for mobility and the wheelchair was visibly soiled. 2. For Resident #86, the facility staff failed to maintain the Resident's wheelchair in a clean and sanitary manner when the Resident was dependent on the wheelchair for mobility and the wheelchair was visibly soiled. 3. For the [NAME] Unit, the facility failed to ensure resident care equipment and the building were maintained in clean condition and good repair. Findings include: Review of the facility policy titled Cleaning of Wheelchairs and GeriChairs (a specialized geriatric chair), undated, included but was not limited to: -In many facilities these items (Wheelchairs/GeriChairs) are the responsibility of Nursing. If so, Environmental Services may be asked to provide cleaning chemicals or equipment. -If these items are the responsibility of Environmental Services, the first step .to arrange to get wheelchairs or Geri Chairs from the residents at a convenient time for the resident. >Materials needed: Pressure washer, Germicide, Brush/sponge, Rags, Buckets. -Steps to do job: a. Set up schedule to collect, wash, dry and return chairs. b. Arrange with nursing to get chairs from residents. c. Take chairs to an open area- basement or a shower room- use a pressure washer or scrub by hand with brush or sponge and germicide solution. d. rinse thoroughly and dry completely with rags (especially seats and wheels). -Additional information: <Proper cleaning procedures prevent the spread of infection. Review of the facility Housekeeping Cleaning Schedule, dated 6/2009 included but was not limited to the following: -Tasks: Wheelchairs. -Method: Germicidal. -Frequency: Bi-monthly. 1. Resident #38 was admitted to the facility in September 2021 with diagnoses including Osteoarthritis, muscle weakness, unsteadiness on feet, and difficulty in walking. Review of Resident #38's April 2025 Physician's orders included but was not limited to: -Health Care Proxy (HCP- appointed person who can make health care decisions for a person that was unable to do so themselves) activated, effective 9/29/21. Review of the Resident's Minimum Data Set (MDS) Assessment, dated 12/11/24, indicated Resident #38: -was unable to participate in a Brief Interview for Mental Status (BIMS) as evident by a score of 99. -was unable to walk 10 feet due to medical condition or safety concern. -used a manual wheelchair. -was dependent on another person for wheelchair mobility. Review of Resident #38's Comprehensive Person-Centered Care Plan included: -has impaired functional mobility related to disease process and required an intervention of a wheelchair for a mobility device, revised 3/25/25. On 4/6/25 at 9:08 A.M., the surveyor observed Resident #38 seated in a wheelchair in the [NAME] Unit hallway. The left-sided fabric leg rest cover on the Resident's wheelchair was stained with a dried white substance. The surveyor also observed the Resident's wheelchair seat and seat cushion had dried white and brown debris present. The surveyor observed Resident #38 seated in a wheelchair in the [NAME] Unit multipurpose room and the left-sided fabric leg rest cover on the Resident's wheelchair was stained with a dried white substance. The surveyor further observed the Resident's wheelchair seat and seat cushion had dried white and brown debris present on the following dates: -4/7/25 at 11:22 A.M. -4/8/25 at 10:00 A.M. 2. Resident #86 was admitted to the facility in August 2023 with diagnoses including weakness and abnormal posture. Review of Resident #86's April 2025 Physician's orders included but was not limited to: -Guardianship (legally appointed person that was responsible for the care of someone unable to manage their own affairs), effective 1/22/25. Review of the Resident's MDS Assessment, dated 2/19/25, indicated Resident #86: -has severe cognitive impairment as evident by a BIMS score of six out of a total possible score of 15. -was unable to walk 10 feet due to medical condition or safety concern. -used a manual wheelchair. -was dependent on another person for wheelchair mobility. Review of Resident #86's comprehensive person-centered care plan included: -Resident #86 had impaired functional mobility related to disease process/condition and required intervention of a wheelchair for a mobility device, revised 10/11/23. On 4/6/25 at 5:05 P.M., the surveyor observed Resident #86 seated in a wheelchair in the [NAME] Unit hallway. The surveyor observed the Resident's right-sided wheelchair arm rest had a dried white and brown substance which continued down the length of the right-hand side of the wheelchair and onto the wheelchair seat cushion. The surveyor also observed a dried brown piece of banana on the back of the Resident's wheelchair seat. On 4/7/25 at 8:49 A.M., the surveyor observed Resident #86 seated in a wheelchair in the multipurpose room on the [NAME] Unit. The Resident's right-sided wheelchair arm rest was observed with dried white and brown substance which continued down the length of the right-hand side of the wheelchair and on the wheelchair seat cushion. The surveyor also observed a dried brown piece of banana on back of the Resident's wheelchair seat. On 4/8/25 at 11:11 A.M., the surveyor observed Resident #86 seated in a wheelchair in his/her bedroom and the right-sided wheelchair arm rest remained with dried white and brown substance which continued down the length of the right-hand side of the wheelchair and on the wheelchair seat cushion. The surveyor observed that a dried brown piece of banana also remained on the back of the Residents' wheelchair seat. During an interview on 4/8/25 at 10:42 A.M., the Housekeeping Manager said the facility did not have a resident wheelchair cleaning schedule. The Housekeeping Manager said he thought the nursing staff might be responsible for cleaning the resident's wheelchairs. The surveyor and the Housekeeping Manager observed Resident #38's and Resident #86's wheelchairs. The Housekeeping Manager said both Resident #38's and Resident #86's wheelchairs were dirty with dried spills and food debris and should have been cleaned. The Housekeeping Manager said that spills and food debris should be cleaned from the Resident wheelchairs when they occur and should not be left to be done by the housekeeping staff only. During an interview on 4/8/25 at 11:05 A.M., the Staff Development Coordinator (SDC) said that resident wheelchairs should be cleaned weekly and as needed. The SDC said the housekeeping department should be cleaning the resident's wheelchairs. The surveyor and the SDC observed the wheelchairs of Resident #36 and #86. The SDC said both Resident #36's and Resident #86's wheelchairs were very dirty with dried food debris and splatters and should be cleaned. During an interview on 4/8/25 at 11:20 A.M., the Director of Nursing (DON) said the housekeeping department was responsible to powerwash the resident's wheelchairs monthly. The DON said nursing staff should wipe spills on resident wheelchairs as they occur, but that deep cleaning should be done monthly and as needed by the housekeeping department. During a follow-up interview on 4/8/25 at 12:45 P.M., the Housekeeping Manager said housekeeping was responsible for cleaning the resident's wheelchairs. The Housekeeping Manager said all resident wheelchairs should be cleaned at least twice a month per the facility policy. The Housekeeping Manager said residents should not have to sit in dirty wheelchairs because nobody would want to sit in a dirty wheelchair. The Housekeeping Manager said the wheelchairs for Resident #38 and Resident #86 were not sanitary or homelike. The Housekeeping Manager was unable to provide evidence of when the wheelchairs for Resident #38 and Resident #86 were last cleaned. 42741 3. During the initial screening process on 4/6/25 the following was observed on the [NAME] Unit: -room [ROOM NUMBER]: significant damage to the wall was observed, including a large gouge in the lower portion of the wall and an area where baseboard wall trim had been pulled off the wall, crumbling dry wall and insulation were observed where the wall met the floor. -room [ROOM NUMBER]: Red dried substance observed on the wall near the window. The resident who resided in the room said a staff member had opened a ketchup packet last week and the ketchup squirted onto the wall by accident and no one had bothered to clean it up. On 4/7/25 from 2:40 P.M. to 3:26 P.M., the following was observed on the [NAME] Unit: -room [ROOM NUMBER]: significant damage to the wall and baseboard was still present. -room [ROOM NUMBER]: Red dried substance remained on the wall near the window. -room [ROOM NUMBER]: A bedside table with dried dark brown debris on the frame, and an area of the wall with drywall repair that was unpainted. During an interview at the time, the resident who resided in the room said someone patched the wall a few months ago but never came back to paint over the patch. The Resident Representative (RR) said he/she visited the resident often, that the resident had been at the facility for over a year, and the RR had not seen anyone wipe down the resident's bedside table where the dark brown substance on the frame was located. On 4/9/25 from 8:35 A.M. to 8:50 A.M., the surveyor and the Housekeeping Director observed the following: -room [ROOM NUMBER]: Red dried substance remained on the wall near the window. -room [ROOM NUMBER]: A Bedside table remained with dried dark brown substance on the frame. During an interview at the time, the Housekeeping Director said the wall in room [ROOM NUMBER] was dirty and needed to be wiped down and the bedside table frame in room [ROOM NUMBER] was dirty and needed to be cleaned. The Housekeeping Director said any staff in the building can let the housekeeping staff know when areas in a resident room needed to be cleaned but the housekeeping staff should also be wiping all surfaces each time they do the daily room cleaning in a room. Review of The Daily Cleaning Checklist provided by the Housekeeping Director indicated the following daily tasks were part of the cleaning routine: -Wipe clean the bedside table from top to bottom. -Wipe down walls. On 4/10/25 from 8:35 A.M. to 9:02 A.M., the surveyor and the Maintenance Director observed the following: -room [ROOM NUMBER]: significant damage remained to the wall. -room [ROOM NUMBER]: drywall repair area that remained unpainted. During an interview at the time, the Maintenance Director said the wall in room [ROOM NUMBER] was in need of repairs. The Maintenance Director said no one had made him or any maintenance staff aware that there was significant damage to the wall and any staff member could notify maintenance when a repair was needed. The Maintenance Director said room [ROOM NUMBER] had a repair done on the drywall but he was unsure how long ago the repair was completed. The Maintenance Director said he would expect maintenance staff to fix the drywall and return within a couple of days to paint the repair. The Maintenance Director said the facility did not have any specific environmental rounds to observe rooms to make sure they were in good repair and homelike, he relied on staff to let him and the maintenance staff know when repairs were needed.

Based on observations, interviews, and record reviews, the facility failed to provide dignified experiences on two occasions during the survey period for one Resident (#119) out of a total sample of 26 residents. Specifically, the facility failed to: -ensure that Resident #119 was clothed so that his/her arm, chest, and back were not exposed while the Resident was sitting in a common area, on two separate occasions, when the Resident was dependent upon staff for dressing. -provide Resident #119 with a dignified dining experience during one noon time meal, relative to drink preferences and assistance for eating when the Resident was dependent on staff for assistance with eating. Findings include: Review of the facility's policy titled Food and Dining Service, dated April 2015, indicated: -Table service is provided for all residents who can and will eat at the table, including wheelchair residents to help them maintain as normal a living pattern as possible. Resident #119 was admitted to the facility in March 2025 with diagnoses including bilateral conductive hearing loss, bilateral visual loss, Attention-Deficit Hyperactivity Disorder (ADHD), and Dementia. Review of Resident #119's person-centered Care Plan, initiated 3/31/25, indicated the following: -has ADL (activities of daily living) deficits and was at risk for nutritional decline relative to Dementia. -determine Resident's food/beverage preferences/eating patterns. -consistent assignments when possible. -explain all procedures and purpose prior to performing task . Review of Resident #119's Nutrition Assessment, dated 4/1/25, indicated the Registered Dietician (RD) assessed the Resident's nutritional status through speaking with facility staff and observing the Resident after the Resident had eaten. On 4/6/25, between 11:02 A.M. and 11:13 A.M., the surveyor observed the following in the Lake Unit Dining Room: -Resident #119 was sitting in a wheelchair, his/her bottom scooted forward on the seat, and his/her back positioned away from the wheelchair backrest. -Resident #119 wore a hospital gown that was open in the back, the ties on the hospital gown were not tied and the Resident's back was exposed. -The lower front of the Resident's hospital gown was positioned on top of the Resident's lap. -The Resident's outer thighs and hips were exposed, and the Resident's incontinence brief was visible. -Four other residents were in the dining room. -No staff were present in the Dining Room at the time. -Several staff members were observed in the hallway. -Resident #119's exposed back could be seen from the hallway outside of the Lake Unit Dining Room. -At 11:13 A.M., Certified Nurses Aide (CNA) #2 entered the Lake Unit Dining Room and approached Resident #119. -CNA #2 exited the room, retrieved a blanket from the linen cart in the hallway, then returned to the Resident and placed the blanket over the Resident's lap. -CNA #2 repositioned Resident #119's hospital gown to cover his/her back but did not tie the ties. During an interview on 4/6/25 at 11:15 A.M., CNA #2 said Resident #119 had been sitting in the Lake Unit Dining Room since breakfast that morning. CNA #2 said the Resident's hospital gown was not tied in the back and his/her back was exposed. CNA #2 said that she retrieved a blanket for the Resident because the Resident was cold. On 4/7/25, between 12:16 P.M. and 1:07 P.M., the surveyor observed the following: -Two staff members assisted Resident #119 from his/her bed into his/her wheelchair. -Resident #119 wore a hospital gown that was open in the back; the ties on the hospital gown were not tied and the Resident's upper back was exposed. -One staff member placed a blanket over Resident #119's lap, then transported the Resident to the Lake Unit Dining Room. -Resident #119 sat at a table with one other Resident (#76), and there were three other residents, one visitor, and three staff members in the dining room. -CNA #10 placed Resident #119's lunch meal on the table in front of the Resident. -Resident #119 did not initiate feeding him/herself and CNA #10 began to assist the Resident to eat at 12:34 P.M. -At 12:33 P.M. Nurse #7 offered coffee to Resident #76, and Resident #119 said, Coffee, yes. -Nurse #7 asked Resident #119 if he/she wanted cream and sugar in the coffee, and the Resident did not respond. -Nurse #7 said she would have to figure out how the Resident wanted his/her coffee, then exited the room. -At 12:37 P.M., Nurse #7 returned to the Dining Room with a cup of black coffee and placed it on the table in front of Resident #119, then placed some sugar packets on the table next to the coffee. At this time, Nurse #7 said, I really don't know how [Resident #119] wants [his/her] coffee to CNA #10. -At 12:53 P.M., CNA #10 stopped assisting Resident #119 to eat, stood up and said she would be right back. -At 12:56 P.M., CNA #1 sat next to Resident #119 and began assisting him/her to eat. -Resident #119's hospital gown had slipped off the Resident's right shoulder and his/her right shoulder, upper arm, and upper back were exposed. -CNA #1 continued to assist Resident #119 to eat and did not adjust the Resident's gown. -At 1:06 P.M., CNA #1 left Resident #119, who was still eating, to assist another resident in the room. -Resident #119's right upper arm and back remained exposed. -At 1:07 P.M. another staff member sat next to Resident #119 and began assisting the Resident to eat. -The Resident's right upper arm and upper back remained exposed until 1:07 P.M., when the staff member assisting him/her to eat at that time repositioned the Resident's hospital gown. -CNA #10 was observed entering and exiting resident rooms in the hallway, visible from the Dining Room, and collecting meal trays. -During the lunch mealtime, Resident #119 did not consume the coffee provided by Nurse #7. During an interview on 4/7/25 at 1:15 P.M., CNA #1 said she did not know why CNA #10 left and did not return to assist Resident #119 with his/her lunch meal. CNA #1 said that CNA #10 said she would be right back, and that CNA #10 never returned to the Dining Room. CNA #1 said she sat with Resident #119 to assist the Resident to eat because the Resident's meal had already started, and no one was assisting him/her to eat. CNA #1 said she had to assist another resident in the Dining Room, so she had to leave Resident #119 to assist the other resident. CNA #1 said when she got up to assist the other resident, another staff member sat to assist Resident #119. CNA #1 said Resident #119 should have been provided with consistent assistance of one staff member to eat during the lunch meal that day because it would have been better for the Resident. CNA #1 also said the Resident's hospital gown should have been tied in the back so that his/her body was covered properly. During an interview on 4/7/25 at 4:45 P.M., the Registered Dietician (RD) said she reviews food preferences for all new admissions, upon admission, with the residents, and with their Health Care Proxy (HCP) if the residents were unable to answer for themselves. The RD said Resident #119 was admitted to the facility in March 2025 and that she had not yet reviewed food preferences for the Resident. The RD said she thought Resident #119 communicated primarily in Spanish. During an interview on 4/8/25 at 10:56 A.M., Nurse #2 said Resident #119 was fluent in English and Spanish and that the Resident could understand both languages. Nurse #2 said the Resident had the ability to understand what was being communicated to him/her and that the Resident's ability to respond was impaired. Nurse #2 said staff were to always ask the Resident about his/her preferences, and if the Resident was unable to respond, then staff were to ask the Resident's HCP. Nurse #2 also said the Resident's HCP had not brought any clothing in for the Resident as yet and staff were dressing the Resident in a hospital gown. Nurse #2 said the Resident was dependent on staff for dressing and that staff should ensure the Resident's body was properly covered.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure that he/she was provided with adequate preventative care measures during an application of and treatment with a hot compress, in an effort to maintain his/her safety to prevent an incident resulting in an injury, when nursing staff did not follow facility policy on how to heat the compress, but instead heated the moist compress in the microwave, applied it to his/her back, and as a result Resident #1 sustained a second-degree burn (burn that affects both the epidermis and second layer of skin (dermis), may cause swelling, red and white blotchy skin, blisters may develop, and pain can be severe) to the area. Findings include: The Facility policy, titled warm soaks, dated 4/2015, indicated Nursing staff would inspect the resident's skin prior to application of a warm soak, wet an appropriately sized dressing with warm water, apply to the area for the prescribed length of time, and inspect the resident's skin after the soak. The Facility policy, titled warm compress, dated 4/2015, indicated nursing staff would moisten the compress with the prescribed solution or heated water, apply the compress to the site to be treated for the time specified, and would check the resident's skin beneath the compress for blanching or erythema (signs of burns). The Facility's Protocol, titled Reheating Food in the Microwave, undated, indicated staff would use caution when handling the plate or container after reheating food in the microwave. The Facility's Investigation Report, dated 12/21/22, indicated Resident #1 had a physician's order for moist compresses to a boil at his/her left scapula. The Investigation Report indicated the Facility's findings were that nursing staff placed the compresses in the microwave, applied them directly to Resident #1's skin. Resident #1 was admitted to the Facility in January 2021, diagnoses included neuropathy, chronic kidney disease, and obesity. Resident #1's medical record indicated he/she had a physician's order, dated 11/28/22, for warm moist compress to be applied to the mass on left back side for 10 to 20 minutes twice daily for wound healing. Resident #1's Weekly Skin Audit, dated 12/19/22, indicated he/she had a blister caused by a hot compress noted on his/her left scapula area. Resident #1's Non- Pressure Wound Evaluation, dated 12/19/22, indicated he/she had a blister at his/her left scapula that was Facility acquired, and measured 3 centimeters (cm) by 2 cm. Review of the Nurse Practitioner's Progress Note, dated 12/21/22, indicated Resident #1 had a second degree (partial thickness of the skin) burn to his/her left scapula where nursing staff had been applying warm compresses to treat a mass on his/her back. During interview on 01/04/23 at 1:03 P.M., Nurse #1 said that on 12/18/22 she had heated a moist facecloth in the microwave for 30 seconds, wrapped it in another towel, and placed it on Resident #1's left scapula. Nurse #1 said that this was how she was told to apply warm compresses. Nurse #1 said she was not aware of Resident #1's burn until the next time she worked. During interview on 01/04/23 at 2:15 P.M., Nurse Supervisor #2 said her practice for applying warm compresses was to moisten a facecloth and microwave it for 20 to 30 seconds, wrap it in a towel, then apply to the Resident's skin. Nurse Supervisor #2 said she was the person who told Nurse #1 how to apply warm compress. During interview on 01/04/23 at 11:46 A.M., the Nurse Practitioner said that on 12/21/22 she assessed Resident #1's left scapula area and saw epithelialized tissue with old skin surrounding it, which was evidence of a blister from a burn. The Nurse Practitioner said Resident #1 told her he/she thought nursing staff used the microwave to heat the compress. The Nurse Practitioner said she would expect nursing staff to follow Facility policy regarding warm compresses, and not use the microwave, as it can become too hot. During interview at 8:15 A.M., the Assistant Director of Nurses said the Reheating of Food in Microwave Protocol warned staff to use caution when handling the plate or container after heating food in the microwave because the microwave could make the plate or container so hot it could cause burns. During interview on 01/04/23 at 10:14 A.M., The Director of Nurses (DON) said nursing staff should moisten a moist compress using the warm water from the sink faucet, and never use the microwave to heat moist compresses as it can become too hot and cause burns.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), the Facility failed to obtain a physician's order for and provide treatment to Resident #1's coccyx wound, which resulted in Resident #1's wound condition to deteriorate. Findings include: The Facility Policy titled, Section S - Skin and Wounds, revised (MONTH) (YEAR), indicated the necessary treatment and services will be provided to promote healing, prevent infection and prevent new pressure injuries from developing. Residents with pressure injuries and those at risk for skin breakdown are identified, assessed and provided appropriate treatment to encourage healing and/or maintenance of skin integrity. Care plans are developed based on individual resident's goals and decisions for treatment. Resident #1 was readmitted to the Facility in (MONTH) (YEAR), [DIAGNOSES REDACTED]. The Hospital Discharge Summary, dated 7/26/17, indicate Resident #1 had a coccyx wound, apply Santyl (an ointment used to debride (the removal of dead skin) to the coccyx area and cover with [MEDICATION NAME] Border (a foam dressing). An Admission/Re-Admission Nursing Evaluation, dated 7/26/17, indicated Resident #1 had an open area to the coccyx with a Santyl dressing applied from the hospital. A Nurse Progress Note, dated 7/27/17, indicated Resident #1 returned from the hospital with an open area to the coccyx that was being treated with Santyl dressing at the hospital. A Weekly Skin Audit, dated 8/1/17, indicated Resident #1 had a coccyx wound. There was no documentation in Resident #1's clinical record to indicate that the physician's order from the Hospital Discharge Summary for treatment to the coccyx wound was transcribed on to the facility's Physician's Order Sheet for Resident #1, or on to his/her Treatment Administration Record, upon readmission to the facility on [DATE]. There was no documentation in Resident #1's clinical record from 7/26/17 through 8/5/17 that a physician's order was obtained for a treatment needed to maintain and promote healing of his/her coccyx wound. A Pressure Ulcer Evaluation, dated 7/26/17 through 8/14/17, indicated Resident #1 had a coccyx wound that originated on 7/26/17, however the 7/26/17 evaluation was blank, the 8/6/17 evaluation indicated Resident #1 was on a MLOA (Medical Leave of Absence). A Nurse Progress Note, dated 8/6/17, indicated Resident #1's coccyx wound deteriorated, the Physician was informed, and a new treatment order was obtained for Santyl. The Surveyor interviewed Nurse #2 at 3:02 P.M. on 5/16/18. Nurse #2 said she did note upon his/her return from the hospital on [DATE], that Resident #1 had a wound on his/her coccyx that was being treated with a Santyl dressing at the hospital. Nurse #2 said she reconciled the Hospital Discharge Orders with the physician, however she did not transcribe the physicians order for Resident #1's coccyx wound treatment on to Resident #1's facility treatment sheets. The Surveyor interviewed Nurse #1 at 3:54 P.M. on 5/16/18. Nurse #1 said she transcribed the re-admission orders [REDACTED]#1's coccyx wound treatment on to Resident #1's facility treatment sheets. The Surveyor interviewed Nurse Supervisor #1 at 12:13 P.M. and 4:33 P.M. on 5/16/18. Nurse Supervisor #1 said she monitors and measures all the wounds in the facility. Nurse Supervisor #1 said she does not have any documentation that she saw Resident #1's coccyx wound from 7/26/17 through 8/13/17, and that she was first made aware of the wound on 8/14/17. The Surveyor interviewed the Director of Nurses (DON) at 4:57 P.M. on 5/16/18. The DON said there were no physician's order, treatment sheet, or care plan for Resident #1's coccyx wound from 7/26/17 through 8/5/17.

Based on record review, observation and interviews, the facility failed to ensure that 1 sampled resident (#10), from a total sample of 24 residents and 6 Extended Survey residents received routine and emergent dental care/services. Findings include: For Resident #10, the facility failed to follow through with the recommendation made by the Dental Provider (on 7/9/13) to have bottom teeth extracted by an Oral Surgeon, and to promptly refer the resident for dental services. Resident #10 was admitted to the facility in 1/2013. [DIAGNOSES REDACTED]. Review of the Initial Minimum Data Set (MDS) Assessment of 1/23/13 indicated the resident had no cognitive deficits or memory impairment, and inaccurately identified that the resident had no problems with natural teeth. Review of the 1/2013 Care Plan for Alteration in Nutrition and Hydration included "Dental Issues" with an intervention for "Dental Consult," as needed (despite the Initial MDS indicated there were no oral problems with the resident's natural teeth). The 3/2/13 Nursing Note indicated that the resident complained of mouth pain; was noted to have redness to the bottom gums, and decayed, broken teeth. The 3/29/13 Physician's visit report indicated that Resident #10 complained of lower teeth pain, and that the resident had an appointment with the Dentist. There was nothing documented in the clinical record between 3/29 to 6/29/13 regarding dental care/consults/notification of family members regarding the status of this resident's teeth. A 6/20/13 Nursing Note indicated that the resident had an appointment to see the Dentist, and that a message was left for the resident's responsible family member to accompany the resident at his/her next appointment to sign consents for treatment. The 7/9/13 dental appointment report indicated recommendations for the resident to have the bottom teeth extracted. On 8/14/13 at 7:46 A.M., the surveyor observed Resident #10 sitting in a w/c (wheelchair) in the doorway of his/her room. The resident's lower teeth were broken, many missing, and appeared to be decayed. During interview on 8/14/13 at 12:00 P.M., Resident #10 told the surveyor that she/he has had problems with the bottom 7 teeth for a long time, and that at home, he/she used to rinse mouth with baking soda and warm water to relieve the pain. Resident #10 said that he/she has had pain in the lower teeth and jaw area for quite some time, and has seen the Dentist, but does not know what the status is since the Dental consult visit. On 8/14/13 at 12:16 P.M., Unit Manager (UM) #2 said that the recommendation for the bottom teeth extraction by the dental services on 7/9/13 had not been followed up with thus far. UM #2 said that a new dentist was going to start at the facility next month in September. UM #2 said that the problem would be getting approval by the resident's insurance provider now for the new dentist. During interview on 8/15/13 at 3:40 P.M., the Director of Nursing said that the facility should have followed up regarding dental care services for Resident #10, especially given the resident's mouth pain and decayed, broken bottom teeth.

Based on observation, record review, policy review and interview, the facility failed to provide clinical interventions for 2 (#2 and #4) sampled residents with significant weight loss out of a total sample of 24 and 6 Extended Survey residents. Findings include: Review of the facility's Weight Assessment and Management Policy, dated 1/2/13, indicated the following: - The purpose of the policy is to monitor nutritional status and monitor each resident for weight maintenance (gain or loss), and to respond appropriately to significant weight changes. - All weights will be evaluated by nursing services and referred to the Dietitian to determine significant change and further assessment. - The Dietitian will review all related information and documentation to look for evidence of identified causes of the weight change. - The Dietitian may make a written recommendation to the Licensed Nurse for communication to the Physician. 1. For Resident #2, the facility failed to provide clinical interventions when the resident experienced a significant weight loss. Resident #2 was admitted to the facility in 6/2011 with [DIAGNOSES REDACTED]. Review of the Change in Status MDS Assessment, dated 11/1/12, indicated the resident was cognitively intact, was assisted with bathing, dressing and grooming, was independent with eating with the exception of needing help setting up the meal. The resident weighed 186 lbs. Review of the Registered Dietitian's progress note, dated 11/7/12, indicated the resident's goal weight is between 175 lbs - 185 lbs. The resident eats 100% of his/her meals. Review of the Registered Dietitian's progress note, dated 2/4/13, indicated that in the past 6 months, the resident lost 11 lbs (5.79%), and the resident's weight now was 179 lbs which was within the goal range. The resident eats 100% of his/her meals. Review of the Quarterly MDS Assessment, dated 4/25/13, indicated the resident was cognitively intact, was an assist for bathing, dressing and grooming, was independent with eating with the exception of needing assist setting up the meal, and had experienced a significant weight loss in the past 6 months (from 186 lbs in 11/2012 to 165 lbs 4/2013). Review of the Registered Dietitian's progress note, dated 5/6/13, indicated in the past 6 months, the resident has lost 13 lbs (7.1%), and his/her weight of 170 lbs was below weight goal range. His/her meal intake was excellent at the present time. Review of the Change in Status MDS Assessment, dated 6/20/13, indicated the resident was cognitively intact, was an assist with bathing, dressing and grooming. Resident #2 was now an assist with eating. The resident's weight was 167 lbs. Review of the resident's June weight record indicated: - 1st week weight was 171.4 lbs., - 2nd week weight was 167.5 lbs., - 3rd week weight was 164.2 lbs., - 4th week weight was 159.7 lbs. with a re-weigh of 162 lbs. The total weight loss in 1 month was 9.4 lbs (7%) which was a significant weight loss. Review of the Alteration in Nutrition care plan, dated as updated 7/2013, indicated the following: - The goal was to promote the resident's weight between 175 - 185 pounds, - Provide house diet, - monitor weights, - Provide medications as ordered, and - Encourage snacks as needed. Review of the Registered Dietitian's progress note, dated 7/3/13, indicated the resident's weight was currently below the weight goal range and further weight loss was not desirable, and to encourage snacks between meals. The note did not mention the significant weight loss experienced in the month of June. In addition, the resident had declined in self feeding, and was now dependent related to increased lethargy. Review of the resident's July weight record indicated: - 1st week weight was 161.7 lbs., - and 3rd week weight was 164.2 lbs. Review of the resident's August weight record indicated: - 1st week weight was 155.0 lbs. - 2nd week 161.9 lbs. During an interview on 8/14/13 at 3:20 P.M., the Registered Dietitian said that when the resident experienced a significant weight loss in 4/2013 she should have put interventions in place at that time, but missed it. In addition, when the resident experienced a second significant weight loss, she was not aware of the significant weight loss that occurred in 6/2013. She said that she was not given the weights until the following week. The Registered Dietitian said that when she was given the weights, she should have noticed the significant weight change then, but again missed it. 2. For Resident #4, the facility failed to provide clinical interventions when the resident experienced a significant weight loss. Resident #4 was admitted to the facility in 1/2013 with [DIAGNOSES REDACTED]. Review of the Alteration in Nutrition care plan, dated 1/2013, indicated the following; - Promote weight between 150-160 pounds, - Provide house diet, - Continual supervision at meals, - Monitor weight, - Encourage intake, and - House supplement (initiated 4/20/13). Review of the Admission Minimum Data Set Assessment, dated 1/10/13, indicated the resident was cognitively impaired, was an assist for bathing, dressing and grooming, was supervised with eating and weighed 153 pounds (lbs). Review of the Initial Nutritional Assessment, dated 1/14/13, indicated the resident was on a regular diet, did not receive any supplements/fortified foods, weighed 153 lbs., and that the goal for Resident #4 was to promote weight between 150-160 lbs. Review of the Registered Dietitian's Progress Note dated 1/23/13, indicated that due to variable intakes, the resident was started on house supplements (4 ounces three times a day). Review of the Resident's weight record, dated 2/2013, indicated the resident now weighed 145.8 lbs. (a 7.2 lb weight loss in 1 month). Review of the Registered Dietitian's Progress Note, dated 2/7/13, indicated the resident's diet was down graded (easier texture to swallow) to a house ground diet. There was no mention of the 7.2 lbs. weight loss in the last month. Review of the Resident's weight record, dated 3/2013,indicated the resident weighed 142.7 lbs. (an additional 3.1 lb. weight loss totaling a 10.3 lbs. weight loss in 2 months). Review of the Quarterly MDS Assessment, dated 3/28/13, indicated the resident was cognitively impaired, supervised for eating and weighed 142 lbs. Review of the Registered Dietitian's progress note, dated 4/8/13, indicated the resident's weight was 142 lbs, had lost 11 lbs (7.2%) in the last 3 months. His/her weight is below range and the slow weight loss is not desirable. The goal was to promote a weight between 150-160 lbs. as well as continuing to supervise and encourage intakes. Review of the Resident's weight record, dated 4/2013, indicated the resident weighed 138 lbs (a loss of 5 lbs in one month). Review of the Resident's weight record, dated 6/2013, indicated the resident weighed 136.4 lbs. Review of the Quarterly MDS Assessment, dated 6/27/13, indicated the resident was cognitively impaired, supervised for eating, received a mechanically altered diet and weighed 136 lbs. In addition, the MDS was coded that the resident experienced a significant weight loss. Review of the Registered Dietitian's progress note, dated 7/9/13, indicated the resident had lost 16 lbs (11%) in the last 6 months. His/her weight was below range and continued weight loss is not desirable. The goal was to promote a weight between 150-160 lbs, as well as to continue to supervise and encourage intakes. Review of the Registered Dietitian's progress note, dated 7/29/13, indicated the resident weighed 136.6 lbs had lost 16 lbs (10.89%) in the last 6 months. Continue to supervise and encourage intakes. On 8/13/13 at 12:30 P.M., the surveyor observed the resident in the dining room sitting in a wheelchair eating lunch. The resident completed 75% of the meal. During interview on 8/13/13 at 2:10 P.M., the Registered Dietitian was asked by the surveyor that when the resident experienced a significant weight loss in 6/2013, why there were no new interventions recommended to prevent further weight loss. The Registered Dietitian said that she does not have a reason why interventions were not implemented, but they should have been. On 8/14/13 at 8:20 A.M., the surveyor observed the resident in the dining room sitting in a wheelchair eating breakfast. The resident completed 75% of the meal.