Every finding on record at Wilson Pines Nursing and Rehabilitation Center

Based on record review and interviews with family, staff, Nurse Practitioner (NP), and Contracted Medical Transportation Company, the facility failed to ensure a resident was safely transported by Transport Technician #1 and Transport Technician #2 when Resident #126's stretcher tipped sideways at an uneven section of pavement as the resident was being pushed to the transportation vehicle through a parking lot following an appointment. The transport technicians and a passerby returned the stretcher to an upright and stable position. The resident was secured to the stretcher and did not fall, however she complained of pain when she returned to the facility. An x-ray revealed a fracture of the fourth through sixth right ribs and she required an increase in the dosage of her pain medication and the addition of an opioid pain medication. The facility also failed to eliminate the potential for an avoidable accident when a cognitively intact resident (Resident #127) was given discharge medications that included 14 tablets of 5 milligram cyclobenzaprine (muscle relaxant) that were prescribed for another resident. Resident #127 realized the facility had provided her with her own medications in addition to the unprescribed cyclobenzaprine when she returned to her home and she contacted the facility to notify them of the error. This deficient practice affected two (Resident #126, Resident #127) of eight residents reviewed for accidents. The findings included: 1. Resident #126 was admitted to the facility on [DATE] with diagnoses that included 2-part displaced fracture of the surgical neck of the left humerus (a break where the upper arm bone is snapped into two main pieces near the shoulder and shifted out of place), closed left hip fracture exacerbated by influenza infection, Chronic Obstructive Pulmonary Disease (COPD), Coronary Artery Disease (CAD), acute kidney injury on chronic kidney disease, paroxysmal atrial fibrillation (heart rhythm disorder where the heart beats fast and out of order starting and stopping on its own), hypertension (occurs when blood pushes too strongly against your artery walls), and hyperlipidemia (commonly known as high cholesterol). Resident #126 had an order dated 1/9/26 for acetaminophen (medication used to treat mild to moderate pain) 650 milligrams (mg) by mouth every 8 hours as needed (PRN) for pain. Resident #126 had an order dated 1/9/26 to record vital signs including pain level every day and evening shift for 14 days. Resident #126 had an order dated 1/14/26 that read apply menthol topical analgesic (medication designed to relieve pain) gel 5% to posterior neck topically every 5 hours PRN for pain. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #126 had moderate cognitive impairment. Resident #126 was dependent on staff assistance to complete all activities of daily living and had frequent episodes of pain with a pain intensity of 9 (scale from 0-10 with zero being no pain and 10 as the worst pain you can imagine). Resident #126's MDS also revealed she had received no pain medication in the 5-day look back period for this assessment. Resident #126 had an order dated 1/20/26 to record vital signs 6 times a day for 3 days for elevated white blood cell count including pain. Review of the care plan revealed a focus area created on 1/9/26 of actual pain, acute, with a goal to be pain free within 1 hour of the intervention as voiced by Resident #126. The interventions included to administer pain medication as prescribed and note the effectiveness; observe for and document characteristics of pain; location, severity, frequency and precipitating factors; and observe for side effects of pain medication. A review of Resident #126's Medication Administration Record (MAR) from 1/9/26 through 2/9/26 indicated she was administered PRN menthol topical analgesic 1 time and PRN acetaminophen 11 times. Her pain level (on a scale of 0-10 with 0 being no pain and 10 being the worst pain possible) was documented once as 3 (1/22/26), once as 6 (2/4/26), once as 8 (2/8/26), and twice as 9 (1/9/26 and 1/30/26). All remaining pain levels were documented as 0 between 1/9/26 and 2/9/26. Review of a facility investigation, completed by the Director of Nursing (DON), documenting events that occurred on 2/10/26 revealed at 12:58 PM Resident #126 was transferred from her bed in the facility onto the Contracted Medical Transportation Company's stretcher which was then placed into their van to be transported to the Imaging Center. At 1:03 PM Resident #126 arrived at the Imaging Center. Upon the completion of the Imaging Center appointment as the Contracted Medical Transportation Company Technicians (Transport Technicians #1 and #2) were pushing the stretcher through the Imaging Center's paved parking lot to return to the facility, the right stretcher wheel hit a pothole in the pavement causing the stretcher to begin to fall to the right. During this time a passerby in the parking lot came to assist the 2 technicians with placing the stretcher upright. At 4:30 PM Resident #126 arrived back at the facility at which time staff heard Resident #126 yell out as Transport Technicians #1 and #2 were leaving the room. A review of the written statement dated 2/10/26 at 4:30 PM by Transport Technician #1 revealed they and Transport Technician #2 transported Resident #126 to an Imaging Center appointment on 2/10/26. While leaving the Imaging Center with Resident #126 on the stretcher there was a pothole/break in the pavement. The right side of stretcher's wheel went over the pothole/break in the pavement and caused the right side of the stretcher to tip to the right. Resident #126 did not fall out of the stretcher. A woman in the parking lot of the Imaging Center came over and assisted them to stabilize the stretcher. A review of the written statement by Transport Technician #2 dated 2/10/26 at 4:42 PM revealed there were several potholes in the pavement of the Imaging Center parking lot. The stretcher with Resident #126 started to tilt to the right and Transport Technicians #1 and #2 grabbed the stretcher as it was going down, and a stranger came to help keep the stretcher upright. Transport Technician #2 noted that Resident #126 did not fall out of the stretcher nor was she injured. A telephone interview was conducted on 7/28/26 at 2:30 PM with the Contracted Medical Transportation Company's Chief Operating Officer. He stated he was traveling and would email additional investigation notes and contact numbers for the technicians (Transport Technicians #1 and #2) that transported Resident #126 on 2/10/26. A follow up email was sent to the Contracted Medical Transportation Company's Chief Operating Officer on 7/28/26 at 4:30 PM. The information requested was not received. An interview with Nurse #3 was held on 7/29/26 at 4:00 PM. Nurse #3 recalled she was working on 2/10/26 when Transport Technicians #1 and #2 returned to the facility with Resident #126 from a scheduled appointment. Nurse #3 stated she asked Resident #126 how her appointment went and Resident #126 said it went fine. Nurse #3 indicated about 30 minutes later Resident #126's family member stated the resident was in pain. Nurse #3 went to Resident #126's room to inquire about the location of the pain. Resident #126 stated the pain was in her back. Resident #126's pain level was an 8 at that time which was higher for Resident #126 than most days. Nurse #3 administered PRN acetaminophen at that time which was effective. Nurse #3 indicated she then proceeded to assess Resident #126 and found a scratch on her right arm that had not been there before her appointment at the Imaging Center. Nurse #3 stated she notified the NP #1 of Resident's pain at that time. A telephone interview was conducted with Resident #126's family member on 7/28/26 at 9:45 am. She stated she met Resident #126 at the facility after her appointment on 2/10/26. She indicated that she remembered Resident #126 was in her bed and stated, damn, they hurt me. The MAR indicated PRN menthol topical analgesic gel and PRN acetaminophen 650 mg were administered on 2/11/26 and Resident #126's pain level was 8. An interview with Nurse #1 was conducted on 7/28/26 at 2:45 PM. She reported on 2/12/26 Resident #126's family member reported the resident was having pain in her right shoulder. Nurse #1 stated Resident #126's pain was occasional in the past but became frequent this day. Nurse #1 stated Resident #126 received pain medication on 2/12/26 and it was effective. Nurse #1 then notified the NP #1 who ordered mobile x-ray to come to the facility to obtain images. Review of the radiology result report dated 2/12/26 at 3:55 PM revealed an acute right posterior (back portion of the ribs) 4th through 6th rib fracture. Resident #126 had an order dated 2/12/26 to assess pain on every shift for 5 days. Resident #126 had an order dated 2/12/26 for tramadol (opioid medication used to treat moderate to severe pain) 50 mg, give 1 tablet every 12 hours PRN for moderate and severe pain for 14 days. The MAR indicated on 2/12/26 PRN acetaminophen 650 mg and PRN tramadol 50 mg was administered and Resident #126's pain level was 10. Resident #126 had an order dated 2/13/26 Lidoderm patch 5%, apply to right ribs topically for rib pain, apply in the morning and remove per schedule. On 2/13/26 Resident #126's order for acetaminophen 650 mg PRN every 8 hours was changed to a routine order of 1000 mg three times a day for pain. The MAR indicated PRN tramadol 50 mg was administered on 2/13/26. Resident #126's pain level on 2/13/26 was 2 and on 2/14/26 through 2/16/26 the pain level was 0. On 2/16/26 Resident #126's order for acetaminophen 1000 mg three times a day for pain was changed to acetaminophen liquid 160mg/5ml (milliliters), give 30 ml by mouth 3 times a day for pain. On 2/19/26 Resident #126's order for PRN Tramadol was discontinued. An interview with NP #1 was held on 7/28/26 at 1:30 PM. She explained that Resident #126 went to an appointment on 2/10/26 via the Contracted Medical Transportation Company and upon her return she complained of pain to her family member. The NP #1 stated the pain was reported to her on 2/12/26 at which time she ordered an x-ray. The x-ray results revealed right rib fractures at ribs #4, #5, and #6. After this incident on 2/10/26 additional pain medications were required to control Resident #126's pain level. An interview with the DON was held on 7/28/26 at 4:35 PM and revealed a family member of Resident #126 had attended the Imaging Center appointment on 2/10/26 and told the Nurse #3 when she was visiting the resident at the facility on the afternoon of the resident's return from the appointment that Resident #126 had stated to her damn, they hurt me. The DON explained that on 2/11/26 she began her facility investigation starting with staff interviews. The DON added on 2/11/26 after hearing from the family member that the resident had complained of worsening pain and the transportation staff hurting Resident #126, she concluded that during the Contracted Medical Transportation Company's transport on 2/10/26 to and from the Imaging Center was when the incident happened. The Contracted Medical Transportation Company completed interviews that included written statements with Transportation Technicians #1 and #2. On 7/29/26 at 9:30 AM an interview was held with the Administrator. The Administrator confirmed he would expect all residents, including Resident # 126, to be transported safely and without injury. The facility provided a corrective action plan that was not acceptable to the State Agency. 2. Resident #127 was admitted to the facility on [DATE]. Review of Resident #127's admission note dated 6/4/26 revealed Resident #127 was alert and oriented to person, place, time, and situation. Review of Resident #127's discharge note dated 6/8/26 revealed Nurse #5 documented Resident #127 was discharged from the facility on 6/8/26 with a friend. The nurse documented she provided the resident with all belongings including her medications with education. During an interview on 7/29/26 at 12:32 PM Nurse #5 stated she was the nurse who discharged Resident #127 on 6/8/26. She further stated when Resident #127 discharged , she had gathered all the resident's medications, provided the medications to Resident #127, educated the resident on what to take and when, and told Resident #127 to call the facility with any concerns. She stated later that week, she did not recall what date, Resident #127 called back and informed the facility that she had also been given one packet of medication for another resident. She did not know what the medication was or how much of the medication the resident received. The nurse stated Resident #131, whose packet of medication had been given to Resident #127, was discharged on 6/7/26, prior to Resident #127's discharge. She told the Director of Nursing that Resident #127 had another resident's medication. During an interview on 7/29/26 at 12:46 PM the Director of Nursing stated Resident #127 called the facility, she could not remember the date but believed she spoke with Nurse #5, and made the facility aware she was provided someone else's medications when she was discharged from the facility. Nurse #5, who discharged Resident #127 on 6/8/26, then called and told the Director of Nursing that Resident #127 got the wrong medication included in with her discharge medications. The Director of Nursing called Resident #127 but did not remember the date. She explained that she remembered Resident #127 called on a Tuesday and she picked the medication up that Wednesday or Thursday of the same week but could not recall exact dates. Resident #127 informed her she got another resident's medication and wanted to let them know. The medication was a single pack containing fourteen 5 milligram (mg) cyclobenzaprine tablets for Resident #131. The Director of Nursing asked if the resident got all of her medication and Resident #127 confirmed she had all of her medication and just got an extra packet of someone else's medications. She told the resident not to take the medication and to not throw the medications away. The Director of Nursing then drove to the resident's home and picked up the packet of fourteen 5 mg cyclobenzaprine tablets. The Director of Nursing returned the medication to the facility to be returned to the pharmacy because Resident #131, who the cyclobenzaprine tablets belonged to, had been discharged on 6/7/26 and his prescriptions had already been called to his pharmacy. He already had all of his medications and was not missing this pack. During an interview on 7/30/26 at 8:38 AM the Administrator stated residents should not be discharged with medications from other residents. During an interview on 7/30/26 at 10:02 AM Nurse Practitioner #1 stated she remembered Resident #127. Nurse Practitioner #1 confirmed Resident #127 was not prescribed cyclobenzaprine. She stated if Resident #127 had taken the 5 mg cyclobenzaprine tablets when they were incorrectly sent home with the resident at discharge, the main concerns would be muscle weakness, drowsiness, and increased risk of falls.

Based on record review and staff interviews the facility failed to provide written advance directive information and/or an opportunity to formulate an advance directive (Residents #8, #9, and #14). This was for 3 of 7 residents reviewed for advance directives.The findings included;a. Resident #8 was admitted to the facility on [DATE] with a diagnosis of stroke.A physician's order dated 4/17/26 was for Do Not Resuscitate (DNR) code status.Resident #8's annual Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact.There was no documentation in Resident #8's medical record of education regarding the formulation of an advance directive and/or that an opportunity to formulate an advance directive was offered.b. Resident #9 was admitted to the facility on [DATE] with a diagnosis of stroke.A physician's order dated 6/16/26 was for Do Not Resuscitate (DNR) code status.Resident #9's significant change in status Minimum Data Set (MDS) assessment dated [DATE] revealed he was moderately cognitively impaired.There was no documentation in Resident #9's medical record of education regarding the formulation of an advance directive and/or that an opportunity to formulate an advance directive was offered.c. Resident #14 was admitted to the facility on [DATE] with a diagnosis of stroke.A physician's order dated 6/27/23 was for Do Not Resuscitate (DNR) code status.Resident #14's annual Minimum Data Set (MDS) assessment dated [DATE] revealed she was severely cognitively impaired.There was no documentation in Resident #14's medical record of education regarding the formulation of an advance directive and/or that an opportunity to formulate an advance directive was offered.On 7/29/26 at 3:00 PM an interview with the Admissions Director indicated that when a resident was admitted to the facility, she spoke with either the resident or their representative about what the resident's desired code status would be and explained the different code statuses to them and also had this same conversation again on readmission. She reported that if the resident or their representative specified something like the resident didn't want to be on a ventilator, she spoke with them about a MOST (Medical Orders for Scope of Treatment is a medical order sheet that translates a seriously ill person's end-of-life care wishes into actionable instructions. It covers key decisions like medical interventions and artificial nutrition/hydration) form. The Admissions Director went on to say she also asked on admission whether the resident had a living will or healthcare power of attorney and if the answer was yes, she asked for a copy and then uploaded it into the resident's medical record. She reported that if the resident or representative indicated they didn't have an advance directive such as a living will or a health care power of attorney, she let them know that if this was something they were interested in, they could let her know and she would send them in the right direction. She stated these conversations were not documented anywhere in a resident's medical record.On 07/29/2026 at 3:49 PM in a telephone interview Social Worker (SW) #1 stated she was the facility's SW from October 2024 until July 11th, 2026. She reported that when a resident was admitted to the facility she usually had a conversation with the Admissions Director to determine if a resident had an advance directive such as a living will or a health care power of attorney. She indicated this was not anything she documented in the record. SW #1 stated that the only thing she really spoke to residents or their representatives about and documented in the medical record was the resident's code status.On 07/29/2026 at 4:18 PM an interview with Social Worker #2 indicated she had been the facility's SW for about 2 weeks. She stated that if a resident had a power of attorney, she made sure this was on file so that when she was doing care plan invitations, she knew who to send the invitation to. She indicated she had not had any conversations with residents or their representatives about formulating advanced directives such as a living will or a health care power of attorney.On 07/30/2026 at 10:15 AM an interview with the Administrator indicated his understanding was that the biggest thing the facility was concentrating on was code status. He reported the other conversations were mainly for information purposes. He stated if a resident or family member reported that the resident had a living will or a health care power of attorney document, the facility requested a copy of this for the resident's medical record.

Based on record review and staff interviews, the facility failed to protect the privacy of Resident # 131 when a medication prescribed for Resident # 131 was sent home with Resident # 127. This practice had the potential to affect 1 of 1 resident reviewed for privacy.Findings included:Resident #131 was admitted to the facility on [DATE]. Resident #127 was admitted to the facility on [DATE]. Review of Resident #127's discharge note dated 6/8/26 revealed Nurse #5 documented Resident #127 was discharged from the facility on 6/8/26 with a friend. The nurse documented she provided the resident with all belongings including her medications with education. During an interview on 7/29/26 at 12:32 PM Nurse #5 stated she was the nurse who discharged Resident #127 on 6/8/26. She further stated when Resident #127 discharged , she had gathered all the resident's medications, provided the medications to Resident #127, educated the resident on what to take and when, and told Resident #127 to call the facility with any concerns. She stated later that week Resident #127 called back and informed Nurse #5 that she had also been given one packet of medication for Resident #131. The nurse stated Resident #131, whose packet of medication had been given to Resident #127, was discharged already and was out of the facility. She told the Director of Nursing who went to Resident #127's house and picked up the packet of medications that was incorrectly included with Resident #127's medications. During an interview on 7/29/26 at 12:46 PM the Director of Nursing stated Resident #127 called the facility and made the facility aware she had someone else's medications (Resident #131) following her discharge. Nurse #5 who discharged Resident #127 then called and told the Director of Nursing that the resident got the wrong medication included in Resident #127's discharge medications. She called Resident #127 who informed her she got the other resident's medication and wanted to let them know. The medication was a single pack containing fourteen 5 milligram cyclobenzaprine (Flexeril) tablets and was for Resident #131. The Director of Nursing then drove to Resident #127's home and picked up the packet of fourteen 5 mg cyclobenzaprine tablets belonging to Resident #131. She stated she remembered Resident #127 called on a Tuesday and she picked the medication up that Wednesday or Thursday of the same week but could not recall exact dates. She remembered that Resident #131's name was on the cyclobenzaprine packet when she picked it up and this was a privacy concern. During an interview on 7/30/26 at 8:38 AM the Administrator stated residents should not be discharged with medications for other residents. He confirmed that a pack of cyclobenzaprine was labeled with Resident #131's name and was sent home with Resident #127 and this was a privacy concern.

Based on observations, record review, and staff and Nurse Practitioner (NP) interviews the facility failed to prime an insulin pen prior to the administration of the insulin (Resident #38) and failed to ensure the resident rinsed their mouth with water without swallowing after the administration of an inhaled medication that contained a steroid (a medication that reduces swelling and calms the immune system) (Resident #50). This was for 2 of 4 residents whose medication administration was observed. The facility's medication error rate was 6.9 % (percent).The findings included:1. Resident #38 was admitted to the facility on [DATE] with a diagnosis of Diabetes Mellitus (DM).Resident #38's annual Minimum Data Set (MDS) assessment dated [DATE] revealed she was moderately cognitively impaired.A physician's order for Resident #38 dated 6/27/26 was for insulin degludec (a long acting injected insulin medication to improve blood sugar control in people with DM) subcutaneous (beneath the skin) insulin pen injector 100 units per milliliter inject 58 units subcutaneously once daily for DM.The insulin degludec manufacturer's instructions for use provided by the facility revealed the following: Priming your [insulin degludec] FlexTouch Pen: Step 7: Turn the dose selector to select 2 units. Step 8: Hold the Pen with the needle pointing up. Tap the top of the Pen gently a few times to let any air bubbles rise to the top. Step 9: Press and hold in the dose button until the dose counter shows '0'. The '0' must line up with the dose pointer. A drop of insulin should be seen at the needle tip. Selecting your dose: Step 10: .Check to make sure the dose selector is set to '0'. Turn the dose selector to select the number of units you need to inject.On 07/28/2026 at 10:50 AM a continuous observation of insulin degludec administration for Resident #38 by Nurse #8 was conducted. Nurse #8 was observed to obtain Resident #38's insulin degludec pen from the medication cart, attach the needle after sanitizing the port, and dial the pen to 58 units. She entered Resident #38's room, explained the procedure to Resident #38, prepared the injection area on Resident #38's right arm, and injected the 58 units of insulin subcutaneously. Nurse #8 then exited Resident #38's room. At 10:55 AM in the hallway outside of Resident #38's room, an interview with Nurse #8 indicated she normally primed insulin pens by dialing the pen to 2 units, attaching the needle, expressing the 2 units, and then dialing the pen to the correct dose before administering it to the resident to ensure the air was out of the needle and the resident got the correct dose of medication, however she was nervous being observed and had forgotten to do it this time.On 07/28/2026 at 1:38 PM in an interview Staff Development Coordinator (SDC) #2 stated Nurse #8 did know she was supposed to prime Resident #38's insulin pen prior to administering the ordered dose of insulin and didn't do that. She indicated Resident #38's insulin pen should have been primed prior to the administration of the ordered dose of insulin to ensure she got the correct dose.On 7/29/26 at 1:15 PM an interview with the Director of Nursing indicated that if the manufacturer's instructions instructed that an insulin pen should be primed before the administration of the ordered dose of insulin, then the nurse should have followed these instructions to ensure the resident received the correct dose of insulin.On 07/30/2026 at 10:09 AM in an interview Resident #38's Nurse Practitioner (NP) stated that if the manufacturer's instructions indicated that the insulin pen should be primed, then it would be important for the nurse to do this to ensure the resident got the full insulin dose that was prescribed for them. She reported she was not aware of any harm to Resident #38 as a result of this one instance.On 7/30/26 at 10:15 AM an interview with the Administrator indicated nurses should be following the manufacturer's instructions when administering medications.2. Resident #50 was admitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disease (COPD).Resident #50's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was moderately cognitively impaired. She did not reject care during the look-back period of this assessment.A physician's order for Resident #50 was for fluticasone furoate 100 micrograms (a steroid medication), umeclidinium 62.5 micrograms (a medication that relaxes the muscles in the airway to improve breathing), and vilanterol 25 micrograms (a medication that relaxes the muscles in the airway to improve breathing) aerosol powder 1 puff once daily for COPD. Wait 1 minute between puffs. Rinse mouth after use.The fluticasone furoate 100 micrograms, umeclidinium 62.5 micrograms, and vilanterol 25 micrograms aerosol powder manufacturer's instructions for use provided by the facility revealed the following: Warnings and Precautions: Candida Albicans (yeast) infection of the mouth and pharynx (throat) may occur. Monitor patients periodically. Advise the patient to rinse his/her mouth with water without swallowing after inhalation to help reduce the risk.On 07/29/2026 at 8:35 AM a continuous observation of medication administration was conducted for Resident #50 with Nurse #9. Nurse #9 was observed to hand the prepared fluticasone furoate 100 micrograms, umeclidinium 62.5 micrograms, and vilanterol 25 micrograms aerosol powder inhaler to Resident #50, who took one puff, and then handed it back to Nurse #9. Nurse #9 was then observed to hand Resident #50 a cup of prepared laxative solution mixed with water which Resident #50 drank and swallowed. Nurse #9 was not observed to provide Resident #50 with water, or to instruct or encourage Resident #9 to rinse her mouth with water without swallowing after the use of the inhaler. At 8:58 AM, outside Resident #50's room, in an interview, Nurse #9 confirmed that she had not provided Resident #50 with water or instructed or encouraged Resident #9 to rinse her mouth with water without swallowing after Resident #50 used her inhaler. Nurse #9 stated she usually did this with other residents and had done this in the past for Resident #50, however Resident #50 did not like to do the rinse after she used her inhaler and had refused to do it in the past. She reported she had not documented or notified anyone of Resident #50's past refusals. She reported she didn't know why she didn't offer or encourage Resident #50 to rinse with water in this instance. She indicated she knew it was important for Resident #50 to rinse with water without swallowing after using her inhaler which contained a steroid to prevent a yeast infection in her mouth.On 07/29/2026 at 11:15 AM the Director of Nursing reported that Nurse #9 should have offered Resident #50 water to rinse and spit every time after Resident #50 used her inhaler to prevent the medication from lingering in Resident #50's mouth and resulting in a side effect such as a yeast infection or mouth discomfort, even if Resident #50 had refused to do this in the past. She stated Nurse #9 should also have documented and reported Resident #50's past refusals so that this behavior could have been incorporated into Resident #50's care plan.On 07/30/2026 at 10:09 AM in an interview Resident #50's Nurse Practitioner stated that it would have been important for Resident #50 to rinse her mouth with water and spit after the use of her inhaler to ensure that no medication remained in her mouth and prevent the overgrowth of yeast due to the steroid medication contained in the inhaler. She reported she was not aware of any evidence that Resident #50 had any mouth discomfort or oral yeast infection.On 7/30/26 at 10:15 AM an interview with the Administrator indicated nurses should be following the manufacturer's instructions and physician's orders when administering medications. He stated Resident #50's past refusals to rinse her mouth with water after using her inhaler should have been documented, and a provider should have been notified.

Based on record review and Responsible Party (RP) and staff interviews, the facility failed to provide a Centers for Medicare and Medicaid Services (CMS) Form 10055- Skilled Nursing Facility (SNF) Advanced Beneficiary Notification (ABN) and Form 10123-Notice of Medicare Non-Coverage (NOMNC) when the facility initiated discharge from Medicare Part A Services when benefit days were not exhausted. This was for 1 of 3 residents (Resident #31) reviewed for beneficiary notice protection. Findings included: Resident #31 was admitted to the facility on [DATE] under Medicare Part A covered skilled services. Resident #31's Medicare Part A covered skilled services ended on 1/22/25. He remained in the facility. A review of Resident #31's medical record revealed no evidence Resident #31 was provided with a CMS SNF-ABN and a CMS NOMNC form. On 4/8/25 at 1:49 PM an interview with the Business Office Manager (BOM) indicated Resident #31's Medicare Part A covered skilled services began on 11/20/24. She stated when these covered services ended on 1/22/25, Resident #31 had used 64 of his 100 covered days. She reported Resident #31 had remained in the facility. On 4/8/25 at 1:22 PM a telephone interview with Resident #31's Responsible Party (RP) indicated she was somewhat familiar with CMS SNF-ABN and CMS NOMNC forms. She stated she did not receive a CMS SNF-ABN and a CMS NOMNC for Resident #31 when his Medicare part A services ended on 1/22/25. On 4/8/25 at 1:26 PM an interview with the Social Worker (SW) indicated she would have been responsible for providing Resident #31 with a CMS SNF-ABN and a CMS NOMNC form when he was discharged from his Medicare Part A covered services on 1/22/25. She reported she had been new to her position in January 2025, and although she had received training on her position duties, she did not recall issuing the forms to Resident #31. She stated at some point the Director of Nursing (DON) had come to her and asked her if she was issuing the CMS SNF-ABN and CMS NOMNC forms, she had not been, and so she began issuing them at that time. In an interview on 4/8/25 at 1:34 PM the DON stated at some point someone came to her and let her know they didn't think the CMS SNF-ABNs and CMS NOMNCs were being issued. She reported she could not recall who notified her, or exactly when this was. She went on to say she had gone to the SW and let her know she was supposed to be issuing these for Medicare Part A residents. On 4/10/25 at 8:48 AM an interview with the Administrator indicated the SW had been relatively new to her position in January 2025, and as a result of this, had not issued the CMS SNF-ABN and CMS NOMNC forms to Resident #31 like she should have.

Based on record review and staff and Responsible Party interviews, the facility failed to accurately code Minimum Data Set (MDS) assessments in the areas of discharge (Resident #99) and dialysis (Resident #46) for 2 of 20 residents reviewed for MDS accuracy. The findings included: 1. Resident #99 was admitted to the facility on [DATE]. A review of Resident #99's electronic health record revealed a discharge MDS assessment was completed on 3/3/25 and indicated the resident was discharged to the hospital. A nurse's note written by Nurse #2 dated 3/3/25 indicated Resident #99 was discharged with his medications, discharge paperwork and all his belongings. The note stated he was picked up by a transportation company. The note did not state Resident #99's discharge location. In an interview with Nurse #2 on 4/9/25 at 9:21 AM she stated Resident #99 was discharged home on 3/3/25. A telephone interview with Resident #99's Responsible Party (RP #1) was conducted on 4/9/25 at 8:18 AM. RP #1 stated Resident #99 was discharged home from the facility on 3/3/25. In an interview with MDS Nurse #1 on 4/9/25 at 9:42 AM she stated Resident #99's discharge MDS should have been coded as discharged home, not the hospital. She further stated the resident was supposed to be discharged on [DATE], but was picked up on 3/3/25. Due to him leaving a day earlier than expected, the discharge MDS was coded as an unplanned discharge which usually meant a resident went to the hospital and was miscoded as such. In an interview with the Administrator on 4/9/25 at 9:53 AM she stated the MDS completed on 3/3/25 should have captured that Resident #99 was discharged home, not the hospital. 48295 2. Resident #46 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease. A review of a Physician order dated 3/12/25 revealed an order for Resident #46 to receive dialysis Monday, Wednesday, and Friday at an offsite dialysis clinic. The admission Minimum Data Set (MDS) assessment dated [DATE] was not coded for dialysis. In an interview with the MDS Coordinator on 4/9/25 at 11:39 am she stated she was aware Resident #46 received dialysis. The interview further revealed that the MDS Coordinator routinely reviewed hospital discharge summaries and coded the MDS based on the reviews. The MDS Coordinator stated Resident #46 should have been coded for dialysis on the 3/13/25 MDS and the failure to do so had been an oversight. In an interview with the Administrator on 4/9/25 at 3:06 pm he stated the MDS completed on 3/13/25 should have captured that Resident #46 received dialysis.

Based on observations, record review and staff interviews the facility failed to implement their infection control practices and procedures when the facility Staff Development Coordinator (SDC) failed to don a gown before entering the room of a resident on Contact Precautions. The facility also failed to implement their policy for Enhanced Barrier Precautions (EBP) when Nurse #1 failed to wear a gown before entering a resident's room to provide medications via a gastrostomy tube (tube inserted directly into the stomach through a small hole in the abdomen to administer hydration, nutrition and medication). The deficient practice occurred for 2 of 20 staff (SDC and Nurse #1) observed for infection control practices. Findings included: 1. Review of the facility policy titled Contact Precautions dated 4/2023 and revised on 6/13/24 stated in part: contact precaution recommendations include wearing a gown when entering room and caring for the resident. Review of the signage on the door to Resident #36's room read in part, Contact precautions, everyone must: wear a gown when entering the room and remove before leaving. During observation on 4/8/25 at 3:45 PM the Staff Development Coordinator (SDC) entered Resident #36's room wearing gloves and no gown. While in the room she helped the resident get comfortable in bed and took a soiled tissue from her to throw away. The SDC removed her gloves and washed her hands before leaving the room. During an interview with the SDC on 4/8/25 at 3:48 PM she stated she thought it was an Enhanced Barrier Precaution room. After reviewing the contact precautions signage on the door, she stated she should have donned a gown before entering the room. An interview with the Director of Nursing (DON), who was also the Infection Preventionist, was conducted on 4/8/25 at 3:56 PM. The DON stated the SDC should have donned a gown before entering the room of Resident #36. She further stated all staff were educated on infection prevention practices upon hire, yearly and as needed. In an interview with the Administrator on 4/8/25 at 4:10 PM he stated infection prevention practices must be followed at all times and the SDC should have donned a gown before entering Resident #36's room. He further stated all residents on contact precautions have an orange sign attached to their door so staff could easily know which precautions were required for which task. 50404 2. Review of the facility policy titled Enhanced Barrier Precautions dated 4/2023 and revised on 6/13/2024 stated in part; Enhanced Barrier Precautions (EBP) are used in conjunction with standard precautions to reduce the risk of Multidrug Resistant Organisms (MDRO) transmission during high-contact resident care activities. Includes the use of both gowns and gloves. The (EBP) apply to residents with the presence of indwelling medical devices with or without the presence of an MDRO infection or colonization. An example of indwelling medical devices includes feeding tubes. During an observation of medication administration on 4/9/25 at 9:53 AM, Nurse #1 entered resident #50's room which had an EBP sign posted on the exterior of the door, to administer medication via gastrostomy tube (a hollow tube inserted directly through the skin of the abdomen into the stomach to deliver nutrition, hydration and medication). Nurse #1 performed hand hygiene prior to entering the room and donned (put on) a clean pair of gloves but did not don a gown. Nurse #1 administered the medication using a feeding syringe (a large 2-part syringe used to administer oral medications) through a gastrostomy tube. In an interview with Nurse #1 on 4/9/25 at 10:15 AM she stated the hall nurse told her she didn't need to wear a gown; she could not remember the name of the nurse. An interview was conducted with the Quality Improvement Nurse on 4/9/25 at 10:25 AM. During the interview she stated the nurse should have worn a gown into a room with an EBP sign posted when administering medications through a gastrostomy tube. During an interview with the Director of Nursing (DON) on 4/9/25 at 10:40 AM, she stated she would have expected the nurse to wear a gown when administering medication through a gastrostomy tube and an EBP sign was posted on the door. An interview was held with the Administrator on 4/9/25 at 12:34 AM, at which time he stated when an EBP sign was posted, he would expect the nurse to wear a gown when administering medications through a gastrostomy tube.

Based on observation and staff interview the facility's Quality Assessment and Assurance Committee failed to maintain implemented procedures and monitor interventions that the committee had previously put in place following the recertification and complaint surveys of [DATE] and [DATE]. This was for a recited deficiency in the area of Food and Nutrition Services (F812). The continued failure during three federal surveys of record showed a pattern of the facility's inability to sustain an effective Quality Assurance Program. The findings included: This tag is cross referenced to: F812: Based on observations and staff interviews the facility failed to dry dishes individually by nesting (stacking dishes/utensils of the same size without an air gap) 4 deep dish pans and 2 large metal mixing bowls, while still wet, on the drying rack for 1 of 3 kitchen observations. During the recertification and complaint survey of [DATE] the facility failed to maintain sanitary conditions in the kitchen by: 1. failing to ensure the dishwasher was rinsing dishes at the correct temperature to sanitize the dishes; 2. by failing to discard expired food and to date opened resealable food items stored in the walk-in refrigerator; 3. by not properly storing and dating open dry food items; and by failing to store food items off the floor. During the recertification and complaint survey of [DATE] the facility failed to (1) label foods items with an open and expiration date and discard expired food items stored for use in 1 of 1 walk-in refrigerator for 1 of 2 kitchen observations and (2) label food items with an open and expiration date stored for use in 1 of 1 walk-in freezer. In an interview with the Administrator on [DATE] at 9:38 am he indicated he felt the continued issue with Food Safety Requirements was because the previous issues differed from the current issue. He further stated the current issue occurred because an employee did not pay attention and moved to fast to complete a task. He stated the facility in-serviced the staff weekly, monthly, and as needed if issues arose. The Administrator stated the facility would review its process and would focus on the whole kitchen and put corrective action in place.

Based on observations and staff interviews the facility failed to dry dishes individually by nesting (stacking dishes/utensils of the same size without an air gap) 4 deep dish pans and 2 large metal mixing bowls, while still wet, on the drying rack for 1 of 3 kitchen observations. Findings included: During observation on 3/3/24 at 10:24 AM 4 deep dish pans and 2 large metal mixing bowls were observed nested on the drying rack. Upon requesting Dietary Cook #1 to remove the top dish, water was visible on the surfaces of the dishes nested together. During an interview on 3/3/24 at 10:24 AM Dietary Cook #1 stated the 4 deep dish pans, and 2 large metal mixing bowls were left over from last night to dry on the drying rack. She did not know why they had been nested in each other. Upon observing the stack of deep-dish pans and large metal mixing bowls, and separating them, she stated the dishes were still wet from last night because they were nested. She further stated staff should not nest dishes that were drying because moisture could be trapped and could cause contamination. During an interview on 3/4/24 at 8:50 AM the Dietary Manager stated when dishes were placed on the drying rack and were wet, they were not to be nested due to the risk of bacterial growth. He concluded the 4 deep dish pans, and 2 large metal mixing bowls should not have been nested the night before while on the drying rack which caused them to still be wet on the morning of 3/3/24. During an interview on 3/5/24 at 2:18 PM the Administrator stated dishes were not to be nested while drying due to the risk of bacterial growth.

Based on record review and staff interviews the facility failed to revise the care plan to reflect the discontinuation of hospice care. This was for 1 of 2 residents (Resident #30) reviewed for hospice and end of life care. Findings included: Resident #30 was admitted to the facility on [DATE] with a diagnosis of dementia. A review of the significant change Minimum Data Set (MDS) assessment for Resident #30 dated 12/15/23 revealed he was not receiving hospice care. A review of Resident #30's care plan dated last revised on 12/28/23 revealed in part a focus area initiated on 9/5/23 and last revised on 12/27/23 for hospice care. The goal was for Resident #30 to be free from pain through the next review. An intervention was spiritual care consult. On 3/4/24 at 2:40 PM an interview with Nurse #1 indicated she was the resource nurse. She stated Resident #30 had been receiving hospice care, but this had been discontinued on 12/8/23. On 3/4/24 at 3:04 PM an interview with MDS Nurse #1 indicated she completed Resident #30's significant change MDS dated [DATE] because his hospice care was discontinued. She went on to say Resident #30's last care plan review was done on 12/28/23. MDS Nurse #1 stated she would have been responsible for ensuring the hospice care focus area was removed from Resident #30's care plan at that time. She went on to say she had missed this. She further indicated she had a check list that she used for updating care plans which included hospice status. MDS Nurse #1 stated this had been an oversight on her part. On 3/6/24 at 9:19 AM an interview with the Director of Nursing indicated Resident #30's care plan should be an accurate reflection of the care he was receiving. She went on to say when Resident #30 had a care plan review and revision on 12/28/24, hospice care should have been removed from his care plan if he was no longer receiving it. On 3/6/24 at 9:26 AM an interview with the Administrator indicated Resident #30's hospice care focus area should have been removed from his care plan if he was no longer receiving it. He stated that's what the checklist was for.

Based on record review, observations and staff interviews, the facility failed to (1) label foods items with an open and expiration date and discard expired food items stored for use in 1 of 1 walk-in refrigerator for 1 of 2 kitchen observations and (2) label food items with an open and expiration date stored for use in 1 of 1 walk-in freezer. These practices had the potential to affect food served to 99 of the 99 residents. Finding included: 1. On [DATE] at 9:48 a.m. in the initial tour of the kitchen accompanied by Dietary Manager (DM), the following items were observed in the walk-in refrigerator: Two containers of frozen solid puree bacon in a box with no date indicating when opened or an expiration date. The Dietary Manager discarded the item. A large, opened container of ranch buttermilk dressing dated open [DATE]. There was no expiration date on the manufacture's label or the container. The Dietary Manager stated opened containers of dressing expired one month after opening and discarded the ranch buttermilk dressing. An unopened 12-pack of boiled eggs indicating no date indicating delivery or an expiration date. The Dietary Manager stated the unopened 12-pack of boiled eggs was pulled out of a box and should have been labeled with the date the box was opened. Dietary Manager discarded the unopened 12-pack of boiled eggs. In an interview with Dietary Aide #1 on [DATE] at 2:20 p.m., she stated she helped put up the food items in the walk-in refrigerator when delivered. She stated food boxes were rotated to the back of the shelves and dated when the box was opened. Boxes of food items without a date were to be discard. She said when she found food boxes without a date, she would write a date on the food item box. In an interview with Assistant Dietary Supervisor on [DATE] at 2:28 p.m., he stated he was responsible for placing new stock on the shelves in walk-in refrigerator. He explained food boxes were to be dated when opened. He further stated dietary staff should relabel any food items removed from the box since those food items need to be used within seven days. He was unable to give a reason why food boxes were found not labeled with dates. 2. On [DATE] at 10:03 a.m. in the initial tour of the kitchen accompanied by the Dietary Manager, the following items were observed in the walk-in freezer: Frozen sliced ham in a box with no date on the box or package indicating delivery or an expiration date. Two unopened packages of frozen waffles with no date indicating a delivery, opening or expiration date. An open box of frozen puree deli meat trays with no date on the package or box indicating the delivery, open or expiration date. An unopened package of frozen hot dogs with no date on the package indicating a delivery date, open date or expiration date. The Dietary Manager discarded the unlabeled items in the freezer and stated staff were to date the boxes of food items when delivered and opened. In an interview with Dietary Aide #1 on [DATE] at 2:20 p.m., she stated she helped put up the food items in the walk-in freezer when delivered. She stated food boxes were rotated to the back of the shelves when delivered and were to be dated when the box was opened. Boxes of food items without a date were to be discard. She said when she found food boxes without a date, she would write a date on the food item box. In an interview with Assistant Dietary Supervisor on [DATE] at 2:28 p.m., he stated he was responsible for placing new stock on the shelves in walk-in freezer. He explained food boxes were to be dated when opened. He further stated dietary staff should relabel any food items removed from the box since those food items need to be used within seven days. He was unable to give a reason why food boxes and packaged were found not labeled with dates.

Based on record review and staff interview the facility's Quality Assessment and Assurance Committee failed to maintain implemented procedures and monitor interventions that the committee had previously put in place following the recertification and complaint survey of 8/27/21. The deficiencies are in the areas of Accuracy of Assessments (641), Accidents (689), Label/Store Drugs and Biologicals (761), and Food Procurement (812). The continued failure during two federal surveys of record showed a pattern of the facility's inability to sustain an effective Quality Assurance Program. Findings included: This tag is cross referenced to: F641: Based on record review, observations and staff interviews, the facility failed to accurately complete the Minimum Data Set (MDS) assessment for isolation (Resident #243), use of a wander guard (Resident #6), for dementia (Resident #58) and discharge status (Resident #90) for 4 of 25 residents whose MDS assessments were reviewed. During the recertification and complaint survey of 8/27/21, the facility was cited for accurately coding an admission Minimum Data Set for smoking. F689: Based on observation, staff interview and record review the facility failed to implement interventions for fall prevention for a resident with a history of falls for 1 of 2 residents reviewed for accidents (Resident #346). During the recertification and complaint survey of 8/27/21, the facility was cited for failing to implement interventions to prevent a resident for smoking in his room and failed to complete a smoking evaluation. F761: Based on observation and staff interviews the facility failed to keep medications secured by storing opened and unlabeled medications in four different medications cups in the medication cart on the 600 hall for 1 of 2 medication carts inspected. During the recertification and complaint survey of 8/27/21, the facility was cited for not discarding expired medications and failing to keep topical medications contained in a resident's room. F812: Based on record review, observations and staff interviews, the facility failed to (1) label foods items with an open and expiration date and discard expired food items stored for use in 1 of 1 walk-in refrigerator for 1 of 2 kitchen observations and (2) label food items with an open and expiration date stored for use in 1 of 1 walk-in freezer. These practices had the potential to affect food served to 99 of the 100 residents. During the recertification and complaint survey of 8/27/21, the facility was cited for failing to maintain sanitary conditions in the kitchen by: failing to ensure the dishwasher was rinsing dishes at the correct temperature to sanitize the dishes; by failing to discard expired food and to date opened resealable food items stored in the walk-in refrigerator; by not properly storing and dating open dry food items and by failing to store food items off the floor. An interview with the Administrator was conducted on 10/16/23 at 3:24 PM. He reported the facility attempted to correct any on-going issues that were identified. The Administrator further stated the facility had some turnover in staff which may have contributed to the repeated citations.

Based on observation and staff interviews the facility failed to keep medications secured by storing opened and unlabeled medications in four different medications cups in the medication cart on the 600 hall for 1 of 2 medication carts inspected. Findings included: An inspection of the 600 hall medication cart on 02/16/23 at 9:45 AM revealed four separate medications cups stored in a drawer on the cart that contained the following unlabeled items: a cup containing 9 pills, a cup of a white liquid, a cup with brown applesauce, and a cup of clear gel. In an interview with Medication Aide #1 on 02/16/23 at 9:45 AM she stated she had opened some of the medications to administer to a resident who refused to take the medications at that time. She reported the resident had told her he was going to the store and would be back in a minute. She stated she finished opening the rest of the medications due at that time and placed the unlabeled mediations in the drawer to administer when the resident returned. She was not able to identify the pills in the cup without looking at the Medication Administration Record in the computer. She explained the applesauce had the medication, Revela, mixed in it. She noted she knew she was supposed to dispose of the medications when the resident refused to take them, and she knew it was not alright to store unlabeled medications in a medication cart, but she thought the resident was coming right back. She took the unlabeled medications to the medication storage room and properly disposed of them. In an interview with the 600 Hall Resource Nurse on 02/16/23 at 9:50 AM she stated it was not acceptable to store unlabeled medications in a medication cart. She noted she would have tried to encourage the resident to take the medications that had been prepared and if unsuccessful, she would have destroyed them.

Based on observation, resident interview, family interview, staff interviews and record review, the facility failed to provide a lunchtime meal to a dialysis resident on 02/01/23, 02/03/23, 02/06/23, 02/08/23, 02/10/23 and 02/13/23 for 1 of 2 residents reviewed for dialysis (Resident #346). Findings included: Resident #346 was admitted to the facility on [DATE] with diagnoses that included hypertensive chronic kidney failure Stage 5. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] documented Resident #346 had moderately impaired cognition. She received hemodialysis. In an interview with Resident #346 on 02/14/23 at 2:30 PM she stated she had not gotten a lunch meal either at the facility or boxed to go since her admission on 01/30/23. She reported she went to dialysis every Monday, Wednesday, and Friday. She explained her chair time at dialysis was 11:30 and she was usually transported between 10:30 and 11:00 each dialysis day. She reported her family had told staff she was not receiving a lunch on dialysis days, but she still had not gotten a box lunch to take with her. She complained she was already weak from dialysis but going from breakfast to dinner without any food made her feel weaker. In a telephone interview with a family member on 02/14/23 at 4:00 PM she stated she had told 3 separate staff members on 3 separate occasions that her mom was very hungry when she returned from dialysis because she was not being provided a lunch on dialysis days and went from 7:00 AM to after 5:00 PM without any food. She reported she had a care plan meeting at the facility earlier that day and told the Social Worker again that her mom was not being fed lunch on dialysis days. She stated the Social Worker told her it was not appropriate to go without lunch. In an interview with the Social Worker on 02/15/23 at 2:36 PM she stated she had a two week care plan meeting on 02/14/23 with the family of Resident #346. She acknowledged she had been told by the family the resident had not been receiving lunch on dialysis days. She stated she had attempted to call the Kitchen Manager twice on 02/14/23 who didn ' t answer or call her back and as the day went on she forgot about it. She did not process the concern. In an interview with Resident #346 on 02/15/23 at 10:25 she stated she went to the nurse ' s station and got a bag of chips and a pack of peanut butter crackers out of the snack box to take to dialysis with her. She had not been provided a box lunch to go. She revealed the chips and crackers when she opened her dialysis duffle bag. There was no other food observed in her dialysis bag. The resident was observed from 10:25 AM to 11:40 AM and no lunch bag was brought to the resident. The transport company was late to pick her up for dialysis. At 11:40 AM Nurse #4 brought the resident a lunch tray. In an interview with Nurse #1 on 02/15/23 at 11:45 AM she stated she walked past Resident #346 ' s room and noticed she had not left for dialysis, so she asked the resident if she had had lunch. She went to the kitchen and got a lunch tray for the resident and also had asked the kitchen staff for a sandwich the resident could take with her. She stated it was her understanding no box lunches went with dialysis residents because the dialysis center would not let them eat there anymore. She stated she did not think the kitchen made box lunches anymore. In an interview with the Kitchen Manager on 02/15/23 at 12:15 PM she stated the kitchen made generic box lunches with no names on them each day for residents to use. She reported she had made 3 box lunches that day and none had been used. She explained each box lunch contained a sandwich, chips, and a drink. The box lunches were available for nurse aides to pick up and give to any resident going to dialysis. She stated it was the responsibility of the nurse aides to come to the kitchen and get a box lunch if a resident needed one. In an interview with Nurse Aide #1 on 02/15/23 at 12:30 PM she stated she provided care to Resident #346 on day shift. She reported she had never gone to the kitchen to get a box lunch for the resident and didn ' t know she was supposed to get the box lunch from the kitchen. In an interview with the Administrator on 02/15/23 at 4:15 PM he stated all dialysis residents were to receive a box lunch to take to dialysis if gone during a meal time. He explained there was a period when the dialysis center would not allow the facility to send food but that was a while ago and no longer applied. He reported he didn ' t realize Resident #346 was going from breakfast to supper with no lunchtime meal. He stated he would look at the process and fix it immediately.

Based on record review, observations and staff interviews, the facility failed to accurately complete the Minimum Data Set (MDS) assessment for isolation (Resident #243), use of a wander guard (Resident #6), diagnosis of dementia (Resident #58) and discharge status (Resident #90) for 4 of 25 residents whose MDS assessments were reviewed. Findings included: 1. Resident #243 was admitted to the facility on [DATE]. Nursing documentation dated 1/30/2023 at 9:37 p.m. revealed the physician and the Resident #243's representative was notified Resident #243 tested positive for COVID-19. Resident #243's care plan dated 1/30/2023 included a focus for an infection related to COVID-19 that was resolved on 2/13/2023. Physician notes dated 1/31/2023 indicated Resident #243 was diagnosed with COVID-19. An infection note documented in Resident #243's medical record dated 1/31/2023 at 9:40 a.m. indicated the day of onset for COVID-19 was 1/30/23, and the type of transmission based precautions (isolation) required was contact and droplet precautions. A COVID-19 laboratory test collected at 11:00 p.m. on 1/31/2023 reported Resident #243 tested positive for COVID-19 on 1/31/2023 at 11:15 p.m. The 5-day admission MDS assessment dated [DATE] indicated Resident #243 was cognitively intact and diagnoses included COVID-19. There was no indication on the MDS Resident #243 was on isolation. Signage for special droplet and contact precautions was observed on 2/13/2023 at 10:47 a.m. outside Resident #243's door. In an interview with MDS Nurse #1, she stated the look back period for Resident #243's MDS assessment was from 1/30/2023 to 2/5/2023. She said the resident had tested positive for COVID-19, and the 5-day MDS did not reflect he was on isolation. She implied isolation was marked on the MDS assessment when documentation reflected residents were provided all services in the room. She further stated at the time of the completion of Resident #243's MDS assessment, COVID-19 restricted Resident #243 to his room, and he should have been coded for isolation. In an interview with the Administrator on 2/16/2023 at 3:46 p.m., he did not have an explanation for why Resident #243 was not coded for isolation on the 5-day MDS assessment and stated Resident #243 should have been coded for isolation. 39731 2. Resident #6 was admitted to the facility on [DATE] with diagnoses that included dementia. A progress note dated 10/28/22 revealed Resident #6 was found propelling to the door of the facility and a wander alarm was placed on her ankle. Resident #6's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated she did not use a wander alarm. During an interview with the MDS nurse on 2/15/23 at 1:22 PM she stated Resident #6's assessment should have been coded to reflect her use of a wander alarm and the error was an oversight. An interview was conducted with the Administrator on 2/16/23 at 3:24 PM. He stated Resident #6's MDS assessment should have been coded accurately to reflect her use of a wander alarm. 43332 3. Resident #58 was admitted to the facility on [DATE]. Review of Resident #58's medical record showed a nurse practitioner's note dated 6/20/22. The note indicated Resident #58 had been seen by a neurologist and was reportedly diagnosed with early symptoms of dementia. Review of Resident #58's medical record showed a psychiatry progress note dated 7/18/22. The note read Dementia: patient seen by neuro since last visit and diagnosed with MNC (Mild Neurocognitive disorder) due to Alzheimer's dementia. Review of the quarterly Minimum Data Set (MDS) dated [DATE] did not include or Alzheimer's Disease or Non-Alzheimer's Dementia diagnoses. An interview was conducted on 2/16/23 at 9:43 A.M. with the MDS Nurse. During the interview the MDS nurse reviewed her worksheet she used to complete Resident #58's quarterly MDS, the medical record, physician progress notes, and the MDS assessments dated 8/1/22. The MDS nurse indicated she had noted Resident #58 had a diagnosis for dementia, the MDS should have been marked to include the dementia diagnosis, and this had been overlooked. An interview was conducted on 2/16/22 at 2:24 P.M. with the Administrator. The Administrator indicated he was told by the MDS nurse Resident #58's dementia diagnosis was not marked when it was identified during the survey. He further indicated the MDS nurse made a mistake and overlooked the diagnosis when she completed the MDS assessment. 37673 4. Resident #90 was admitted to the facility on [DATE]. She was discharged on [DATE]. Review of a progress note written on 01/03/23 documented Resident #90 was discharged at 5:30 PM and left the facility by wheelchair with her husband. Discharge instructions, medication administration, and medications were sent with the resident. Review of the facility Discharge Instructions and Plan of Care Report dated 01/03/23 documented the resident was discharged to home. Review of the discharge MDS assessment dated [DATE] documented Resident #90 was discharged from the facility to an acute hospital, Line A2000. In an interview with MDS Nurse #3 on 02/16/23 at 11:13 AM she stated, after reviewing the records, the MDS assessment should have been coded as the resident went home, not to the hospital. She thought she just clicked on the wrong button when completing the assessment.

Based on record review and staff interviews, the facility failed to provide a Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facility Advanced Beneficiary Notice and CMS-10123 Notice of Medicare Non-Coverage (NOMNC) (Resident #65) and failed to provide a Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facility Advanced Beneficiary Notice (Resident #15) prior to discharge from Medicare Part A skilled services for 2 of 3 residents reviewed for beneficiary protection notification review. The findings included: 1. Resident #65 was admitted to the facility on [DATE]. Resident #65's Medicare Part A skilled services ended on 12/9/22. She remained in the facility. Record review revealed that Resident #109 was not given the CMS-10555 Skilled Nursing Facility Advanced Beneficiary Notice (SNF-ABN) or CMS-10123 Notice of Medicare Non-Coverage (NOMNC). During an interview with the Business Office Manager on 2/13/23 at 3:04 PM she reported she was unable to locate the required forms for Resident #65. An interview was conducted with the Administrator on 2/13/23 at 3:30 PM who indicated Resident #65 should have received the CMS-10555 and CMS-10123 as required by Federal guidelines. 2. Resident #15 was admitted to the facility on [DATE]. Resident #15 received Medicare Part A skilled services beginning on 10/6/22 and ending on 11/18/22 . She remained in the facility. Record review revealed that Resident #427 was not given the CMS-10555 Skilled Nursing Facility Advanced Beneficiary Notice (SNF-ABN). During an interview with the Business Office Manager on 2/13/23 at 3:04 PM she reported the facility was not using the correct form. She stated she had was notified a few weeks ago the facility was using the wrong form and was now using the correct form. An interview was conducted with the Administrator on 2/13/23 at 3:30 PM who indicated Resident #15 should have received the CMS-10555 SNF-ABN as required by Federal guidelines.

Based on resident, family and staff interviews the facility failed to treat a resident with dignity and respect by speaking harshly to her and asking the resident if she had been playing in her poop for 1 of 5 residents reviewed for dignity (Resident #346). Findings included: Resident #346 was admitted to the facility on [DATE] with diagnosis of hypertensive chronic kidney disease Stage 5 and a history of falls. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] documented Resident #346 had moderately impaired cognition. She required extensive assistance from staff with toileting. She was frequently incontinent of bowel and bladder. Review of the care plan dated 02/10/23 for Resident #346 included, in part, the following focal area: At risk for unmet needs and/or compromised dignity. The goals for Resident #346 were to maintain dignity and have decreased episodes of anxiety. Interventions included, in part, to talk with resident in a low pitch, calm voice. In an interview with Resident #346 on 2/14/23 at 2:30 PM she stated a nurse aide came in on third shift to answer her call bell and she took the residents hands and said, Let me see your hands. Are you playing in your poop? The resident stated the nurse aide spoke harshly to her, made her feel like a child, and she felt humiliated. She said she felt like the nurse aide on third shift was aggravated when she provided care to her and spoke harshly to her. She did not know the name of the staff member but commented it was only one nurse aide who spoke harshly to her, and the rest of the staff were sweet. She stated when that nurse aide was on, she would try to hold her bowel movements and not ring the bell, but she couldn't. She described the nurse aide as small and cute and not someone you would think was mean because she was so small and cute. She could not recall the exact date when the nurse aide asked her if she had been playing in her poop but she noted it was after the day she had fallen (01/31/23) and it was not on a dialysis day, so it had to have been on a Tuesday, Thursday, or weekend night shift. In an interview with a family member on 2/14/23 at 4:00 PM she stated the resident had told her a nurse aide spoke harshly to her. She said she had not reported it to the facility because she had already complained 3 times about [Resident #346] not getting lunch on dialysis days and she didn't want her to be tagged by staff as a problem resident. In an interview with the QA Nurse on 02/15/23 at 8:15AM she reported facility staff had met after the survey team left the day before, and it was decided to discontinue some of the fall interventions for Resident #346 because her cognition had improved since admission. On 02/15/23 at 3:36 PM a telephone interview was conducted with Nurse Aide #6. She confirmed she had cared for Resident #345 on 3rd shift on 02/01/23 as documented on the working schedule. She stated she had never spoken harshly to Resident #346 or asked her if she had been playing in her poop. She had never heard any other staff member speak harshly to residents. She stated she would tell the nurse if she did. On 02/15/23 at 4:00 PM a telephone interview was conducted with Nurse Aide #4. She confirmed she had cared for Resident #346 on 3rd shift on 02/03/23, 02/07/23, 02/09/23 and 02/12/23 as documented on the working schedule. She stated she had never spoken harshly to Resident #346 or asked her if she had been playing in her poop. She reported she had never heard any staff speak harshly to Resident #346 or any other resident. She concluded if she ever did, she would call the administrator on call or the supervisor. On 02/15/23 at 4:16 PM a telephone interview was conducted with Nurse Aide #5. She confirmed she had cared for Resident #346 on 3rd shift on 02/10/23 as documented on the working schedule. She stated she had never spoken harshly to Resident #346 or asked her if she had been playing in her poop. She reported she had never heard other staff members speak harshly to Resident #346 or any other resident. She concluded she would tell the nurse if she ever did. On 02/15/23 at 4:20 PM a telephone interview was conducted with Nurse Aide #8. She stated she worked at the facility through an agency. She confirmed she had cared for Resident #346 on 3rd shift on 02/04/23. She stated she had never spoken harshly to Resident #346 or asked her if she had been playing in her poop. She reported she had never heard any other staff member speak harshly to Resident #346 or any other resident. She concluded she would report it immediately to the nurse if she ever did. On 02/15/23 at 4:47 PM a telephone interview was conducted with Nurse Aide #7. She stated she worked at the facility through an agency. She confirmed she had cared for Resident #346 on 3rd shift on 02/02/23, 02/05/23, and on 02/08/23 as documented on the working schedule. She stated she had never spoken harshly to Resident #346 or asked her if she had been playing in her poop. She reported she had never heard any other staff speak harshly to any resident. If she ever did, she would tell the nurse. In an interview with the Administrator on 02/15/23 at 4:10 PM he stated it was never acceptable for a staff member to speak harshly to any resident. He declared no resident at the facility had ever been branded as a problem resident for reporting a concern and never would be.

Based on observation, staff interview and record review the facility failed to implement interventions for fall prevention for a resident with a history of falls for 1 of 2 residents reviewed for accidents (Resident #346). Findings included: Resident #346 was admitted to the facility on [DATE] with diagnoses that included falls, osteoarthritis, and restless leg syndrome. Review of a health status note written on 01/31/23 at 12:52 AM documented: PT [Physical Therapy] walked past resident's room and found resident on the bathroom floor . [Resident #346 was] reeducated to use call bell when needing to ambulate, to lock (wheelchair) when transferring, and to wear non-skid footwear. Quality Assurance-Falls Review (at risk for or actual) dated 2/2/23 was reviewed and documented Resident #346 had a fall on 01/03/23. Resident had non-skid (gripper) socks to feet when she fell . She was reminded to call for assistance. Interventions included to place call bell within reach, place bed in lowest position, and continue current fall interventions. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] documented Resident #346 had moderately impaired cognition. She required extensive assistance with most activities of daily living. She required limited assistance from staff with walking in room using a walker or a wheelchair. She had a fall prior to admission and fell after admission to the facility with injury (not major). Review of the care plan for Resident #346 dated 02/10/23 documented a focal area of: Risk for falls characterized by history of falls multiple risk factors related to, in part, weakness, impaired balance, impaired vision, disrobing, removal of brief, frequent incontinence of bowel and bladder, impaired short and long term memory. The goal was for Resident #346 to be free of falls through the next review. Interventions included, in part, bed in lowest position and ensure roll bolster (roll guard) is in place to outer edge of bed. An observation of fall precautions in place was made at 2:30 PM on 02/14/23. Resident #346 was laying on her bed awake. She had socks on that were not non-skid, the roll guard was standing in the corner of the room, and the bed was in a high position (chest high). The resident revealed a large healing skin tear on her left leg and on her left arm she had sustained from a fall at the facility. The Quality Assurance (QA) Nurse was interviewed in the resident ' s room on 02/14/23 at 3:05 PM. She stated the resident should have had the bed in the lowest position and acknowledged it was in a high position, the roll guard should have been on the bed and it was not, and the resident should have had non-skid socks on and she did not. She opened the resident ' s closet door and pointed out the Care Kardex that listed instructions for caregivers that included non-skid socks, bed in lowest position and roll guard to edge of bed. During the interview the QA Nurse lowered the resident ' s bed to a low position and the resident sat up and put her legs over the side of the bed. She stated she would put non-skid socks on the resident. A follow-up observation on 02/14/23 at 3:30 PM revealed the resident was lying in bed that was in the lowest position, non-skid socks were on the resident's feet and the roll guard was on the outside edge of the bed.

Based on observations and staff and chemical company technician interviews, the facility failed to maintain sanitary conditions in the kitchen by: 1. failing to ensure the dishwasher was rinsing dishes at the correct temperature to sanitize the dishes; 2. by failing to discard expired food and to date opened resealable food items stored in the walk-in refrigerator; 3. by not properly storing and dating open dry food items; and by failing to store food items off the floor. These practices had the potential to affect all residents. Findings included: 1. Observation of the single conveyer dual temperature dishwasher on [DATE] at 10:34 AM revealed an initial wash temperature of 150 degrees Fahrenheit (F) and a final rinse temperature of 138 degrees F. Subsequent observation at 10:50 AM revealed a wash temperature of 163 degrees F and a final rinse temperature of 136 degrees F. Interview on [DATE] at 10:50 AM with the Dietary Manager (DM) revealed she was unsure of what the temperature should be to sanitize the dishes. Interview on [DATE] at 2:07 PM with the Chemical Company technician who was at the facility, revealed he came at least every 2 months or as needed to make sure the dishwashing machine was working correctly. The Chemical Company Technician was informed that the final rinse temperatures on [DATE] were never observed to be at or above 180 degrees. The Technician looked down at the machine and the temperature booster for the machine was off and he flipped the switch on, and the final rinse temperature rose to 180 degrees within a few minutes. On [DATE] at 2:30 PM an interview was conducted with the Chemical Company Technician by phone, and he stated that the dishes were sanitized in the final rinse and the temperature needed to be at least 180 degrees for sanitization to occur. Observation on [DATE] at 2:35 PM of the High temperature rinse aid's directions for use with High Temperature Dish Machines a minimum rinse temperature of 180 degrees F must be maintained during the rinse cycle for proper thermal sanitization. Interview with the DM and the Company Dietary Consultant on [DATE] at 2:49 PM revealed they were unaware that sanitization occurred in the high temperature rinse cycle. The Company Dietary Consultant stated that meals would need to be served on paper plates and plastic utensils and cups until the dishes could be rewashed and the machine was checked out again by maintenance. Interview with the Administrator on [DATE] at 10:49 AM revealed he had heard about the dishwasher from the DM and thought the water temperature booster had accidently been shut off. He further stated that the residents did eat off paper plates and plastic utensils and cups the night before. 2. Initial tour of the walk-in refrigerator on [DATE] at 10:27 AM revealed a plastic resealable bag with cheese slices in it and a Styrofoam container with cooked bacon and eggs undated. Another plastic resealable bag with ham and cheese slices and a bag of French toast was undated. Ham spread in a plastic container had an expired date of [DATE]. Interview with the DM on [DATE] at 10:30 AM revealed all items in the walk-in refrigerator should have dates on them and they would have to be discarded along with the expired ham salad. 3. On [DATE] at 10:23 AM an initial observation of the dry storage room with the Dietary Manager (DM) revealed an opened bottle of vanilla extract without the lid and aluminum foil placed on top and was not dated. An open box of rice and an open box of instant mashed potatoes were not in airtight containers and were not dated. A case of water and a cardboard box of chips were on the floor. Interview with the DM on [DATE] at 10:26 AM revealed the opened items in the dry storage room should have been stored in airtight containers and dated. She further stated the items should not be stored on the floor. Interview with the Administrator on [DATE] at 2:15 PM revealed that he expected food that was expired to be thrown away and not in the walk-in refrigerator and opened foods should be dated. He further stated that he had heard about the temperatures in the dishwasher being too low and he indicated it should not have happened.

Based on interviews with staff, resident, and physician, and record review the facility failed to notify physician when scheduled medications were not administered to one of one resident reviewed for notification of change. (Resident #78). Findings included: Resident #78 was admitted to facility on 07/31/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent admission Minimum Data Set (MDS) dated [DATE] revealed Resident #78 was cognitively intact. During an interview on 08/23/21 at 11:31 AM Resident #78 revealed that when she returned to facility at 10:37 PM from a day out with family on 08/21/21 she requested from Nurse #2 her medications that were scheduled for the evening to be given. She reported that she was told by the Nurse #2 that she returned too late to receive medications. Resident #78 did not receive her scheduled medications that evening. Record review of Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The medications not administered included [MEDICATION(S)], Trazadone, [MEDICATION(S)], [MEDICATION(S)], Oxycodone, [MEDICATION(S)], and [MEDICATION(S)]. The chart code documented by Nurse #2 for the medications that were not administered was #3-absent from facility. During an interview on 08/25/21 at 10:32 AM Nurse #1 revealed that Resident #78 signed out of the facility at 11:10 AM on 08/21/21 to spend day with sister. She stated that Nurse #2 reported on 08/22/21 at the 07:00 AM shift report that Resident #78 did not return to the facility until late and was not given her scheduled medications for the evening shift on 08/21/21. During a phone interview on 08/25/21 at 10:42 AM Nurse #2 revealed Resident #78 was expected to return to facility at 09:00 PM. She stated that Resident #78 had not returned to the facility and at 10:00 PM she made a call to the family and left message regarding return. Nurse #2 reported that Resident #78 returned to facility at approximately 10:50 PM. Nurse #2 confirmed that Resident #78 did not receive her medications that evening because she was not in the facility when the medications were scheduled to be administered. She stated that she did not notify the physician of medications not administered or to obtain permission to administer the medications late to Resident #78 upon return to facility. Nurse #2 was unable to state why she did not notify the physician about the medications that were not administered for Resident #78. During an interview on 08/25/21 at 11:07 AM the Quality Assurance Nurse revealed that the physician should have been called regarding medications not being administered. During an interview on 08/25/21 at 11:17 AM the Assistant Director of Nursing (ADON) revealed that nurses are educated to notify the physician when medications are not administered. The ADON stated that the physician could have given permission for medications to be administered late. During an interview on 08/25/21 at 02:38 PM Family Nurse Practitioner (FNP) revealed that she was notified today that Resident #78 went out with family on 08/21/21 and medications were not administered. FNP stated that she would have preferred that nursing contacted provider to have the medication administered when Resident #78 returned. FNP reported that the facility staff can contact them regarding resident at any time. During an interview on 8/27/21 at 3:48 PM Medical Director revealed that Nurse #2 should have contacted provider regarding Resident #78's missed medications when returning to facility from LOA. Medical Director reported that the office has an on-call system and can be reached at any time.