Advanced Care Center

Based on interviews and record reviews the facility did not ensure two residents (#1 and #2) out of four residents reviewed had physician orders to ensure the residents received necessary care and services upon admission.Findings included: 1.) An interview was conducted on 10/15/2025 at 10:06 a.m. with the resident representative (RR) for Resident #1. The RR said the resident had been discharged from the facility and was in the hospital for an issue with a foot wound. The RR said she had concerns about the facility not giving Resident #1 insulin when he was initially admitted to the facility. She said the resident finally received insulin, but only half of his normal dose. The RR said she had spoken to the nurse assigned to Resident #1 about her concerns. The RR said the resident also informed the nurse he was supposed to be on insulin his first day in the facility and asked about his insulin multiple times and filed a grievance.Review of admission Records showed Resident #1 was admitted from the hospital on 9/24/25 with diagnoses including type 2 diabetes mellitus (DM) with foot ulcer, type 2 diabetes with other specified complications, diabetes mellitus with diabetic peripheral angiopathy, and peripheral vascular disease.Review of Resident #1's Brief Interview for Mental Status (BIMS), completed 9/25/25, showed a score of 14, indicating he was cognitively intact.Review of Resident #1's hospital Medication Discharge Report, dated 9/24/25, showed:Stop Taking the Following Medications-Insulin Aspart (Novolog Flex pen 100 units (u)/milliliter (ml) injectable solution. Sliding scale. Subcutaneous. Three times a day before meals.-Insulin Glargine (Lantus Solostar pen 100 u/ml subcutaneous injection. 20 u once a day.No additional medications for diabetic control were listed on the Medication Discharge Report.Review of Resident #1's Hospital Medication Administration Record (MAR) showed the resident last had Insulin Aspart 14 u on 9/24/25 at 6:01 p.m. and Insulin Glargine 10 u on 9/23/25 at 8:57 p.m.Review of Resident #1's progress notes did not show any documentation the discharge medication list was reviewed and reconciled with a provider upon admission.Review of Resident #1's weights and vitals showed no documentation the resident's blood glucose level was checked at the facility until 9/26/25 at 9:21 p.m., when the level reading was 240 milligram (mg)/deciliter (dL). (Normal range: fasting: 70-140 mg/dL; Post-meal: less than 160 mg/dL)Review of Grievance/Concern Reports showed a grievance filed by Resident #1 on 9/25/25 with concerns including the facility not having his medications at admission.Review of Resident #1's facility orders did not reveal any insulin orders until:-Novolog Flex Pen Subcutaneous Solution Pen-injector 100 u/ml (Insulin Aspart) Inject as per sliding scale: if 150 - 200 = 2 units give glucagon notify MD of BS <60; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units give 10 units and notify MD of BS > 400, subcutaneously before meals and at bedtime for diabetes mellitus (DM) type II for 7 Days. Start date 9/26/25.-Insulin Glargine Subcutaneous Solution. Inject 10 units subcutaneously two times a day for diabetes mellitus. Start date 9/29/25. Review of Resident #1's facility MAR showed Novolog insulin was administered for the first time of 9/26/25 at 4:40 p.m. and the resident had a blood glucose level of 240 mg/dL, two days after admission to the facility. The MAR showed Insulin glargine was administered for the first time on 9/28/25 at 6:00 a.m., four days after admission to the facility.2.) An interview was conducted on 10/15/25 at 6:15 p.m. with the RR for Resident #2. The RR said when Resident #2 arrived at the facility it apparently wasn't clear in the hospital paperwork that the resident was on insulin. The RR said when the admitting nurse reviewed medication with them, they notified the nurse the resident needed insulin. The RR said Resident #2 went a day or so without insulin but didn't have any negative effects.Review of admission Records showed Resident #2 was admitted from the hospital on 9/27/25 with diagnoses including diabetes mellitus type II, chronic obstructive pulmonary disease, and obesity.Review of Resident #2's hospital paperwork did not list insulin on the Med Rec Discharge meds however, the Medication Discharge Summary from the hospital showed the resident was on Insulin, regular 70/30 100 u/ml 20 u twice daily before meals and Insulin Lispro 100 u/ml before meals and at bedtime.Review of Resident #2's progress notes did not show any documentation the discharge medication list was reviewed and reconciled with a provider upon admission.Review of Resident #2's orders did not show any orders for insulin put in at the facility upon admission.Review of Resident #2's Weights and Vitals Summary showed the resident's blood glucose level was not checked until 9/29/25 at 1:37 p.m., two days after admission to the facility, with a reading of 296 mg/dL.Review of Resident #2's facility orders and MAR showed an order for Novolin 70/30 flexpen 100 u/ml. Inject 45 u subcutaneously before meals related to type 2 DM, start date 9/29/25. The first dose was signed off as administered on 9/29/25 at 4:30 p.m. and the resident had a blood glucose level of 393 mg/dL. An order for Novolin 70/30 flexpen 100 u/ml. Inject 25 u subcutaneously at bedtime related to type 2 DM, start date 9/29/25. The first dose was signed off as administered on 9/29/25 at 9:00 p.m. The resident's blood glucose level was 397 mg/dL.An interview was conducted on 10/15/25 at 4:40 p.m. with Staff D, Licensed Practical Nurse (LPN). Staff D said when admitting a resident to the facility the resident came with a discharge medication list from the hospital, and the admitting nurse entered those orders into the facility orders. Staff D said the day after admission the supervisors reviewed the new admission and the orders. Staff D said the admitting nurse did not call the doctor or send the orders to the doctor to be reviewed. Staff D said when Resident #1 was admitted she was his assigned nurse but Staff E, Registered Nurse (RN) did his admission. She said she didn't recall seeing anything about Resident #1 being diabetic but did see that it said stop insulin. She said the resident's hospital paperwork was confusing. Staff D said a couple of days after admission she checked Resident #1's blood glucose and it was high so she called the provider and they gave an order for long acting insulin.An interview was conducted on 10/15/25 at 5:00 p.m. with Staff E, RN. He said when there is a new admission the resident came from the hospital with paperwork including their medication reconciliation. He said the admitting nurse entered the orders from the medication reconciliation into he computer. He said the nurse did not call and go over the medications with the provider. Staff E said usually the provider already knew the resident from the hospital anyway. He said the provider reviewed the medications when they came in and saw the resident. He said the providers are usually in the building twice a week. Staff E said if the admitting nurse had any questions, they could call the discharge nurse at the hospital or the provider. He said management also reviewed new admissions the next day. Staff E said if a resident came in on insulin or oral DM medications, they would put in an order for blood glucose checks to be done. Staff E said he did the admission for Resident #1. He said he wasn't concerned that the hospital medication reconciliation said to stop insulin because he had seen the hospital stop it for residents before at discharge. He said Resident #1 told him he was on insulin. Staff E said he had to show him the hospital paperwork where it said to stop taking insulin. He said he told the resident that is what he had to go by.An interview was conducted on 10/15/25 at 5:28 p.m. with the Director of Nursing (DON). She said when there is a new admission the facility would get some paperwork ahead of time, but the resident would also come with their discharge medication list from the hospital. The DON said the admitting nurse got the paperwork, did all the necessary evaluations and consents, go over medications with the resident and/or family, then call the doctor to get verification if medications are ok. The DON reviewed the records of Resident #1 and #2 and confirmed she did not see any documentation the admission medications were reconciled with a provider upon admission. She said she would expect there to be a nurses' note saying the provider was called and medications were reviewed. The DON said she expected the nurses to call the provider before putting orders into the computer for a resident. The DON said as far as blood glucose checks she said there were batch orders that everyone can have a blood glucose check for signs or symptoms of high or low blood sugar. She said if a resident says they are diabetic the nurse should do blood glucose checks. The DON said for Resident #1 the fact he wasn't getting insulin was brought to the facility's attention when the resident filed a grievance. She said she would have expected the nurse to call the doctor if a resident told them they should have insulin and were not getting it. The DON said regarding Resident #2, just because she is diabetic doesn't mean she would get insulin or need blood glucose checks. She said it was concerning that nurses were not calling the provider to reconcile medications on admission. The DON said the facility did have an admission checklist, but it depended on the nurse if they used it or not.A follow-up interview was conducted with the DON on 10/15/25 at 6:45 p.m. The DON said the day after a resident's admission the resident is reviewed in the morning clinical meeting. She said they ensure everything is in the record and match what came from the hospital. The DON said she was not there when Resident #1 and #2's records would have been reviewed, and the clinical team didn't remember if they reviewed them.An interview was conducted on 10/15/25 at 6:48 p.m. with the Assistant Director of Nursing (ADON). She said when reviewing new admission in the clinical meetings the Unit Manager (UM) reviewed the admission paperwork and the resident's electronic medical record if pulled up on the big screen. She said the UM goes through the paperwork from the hospital and they all make sure the orders were entered correctly. She did not recall if Resident #1 and #2's records were reviewed.An interview was conducted on 10/15/25 at 6:55 p.m. with Staff F, LPN/UM. Staff F said she did admission record reviews and in that process, she made sure batch orders were in place, she checked medications on the discharge paperwork and ensured correct doses were ordered. Staff F said she did not recall Resident #1 or #2's review. She said seeing stop insulin on the hospital discharge paperwork wouldn't necessarily make her question it because some residents are on insulin temporarily in the hospital, but if a resident and/or RR said the resident was on insulin she would call the doctor or expect the nurse to call and get orders for insulin and/or blood glucose checks.Residents #1 and #2 primary care provider could not be reached.Review of the facility admission Checklist included but not limited to: -Add/Verify Attending Physician-Input Diagnosis and review H&P (history and physical)-Review hospital discharge orders-Add/Verify MD (medical doctor) orders from discharge med reconciliation ensure appropriate diagnosis, route, parameters. Ensure each diagnosis is covered in medication regimen if applicable.On 10/15/25 at 7:04 p.m. the DON stated the facility did not have a policy on medication reconciliation or diabetes management or the admission process.Review of a facility policy titled Physician Services, revised February 2021, showed: Policy Statement - The medical care of each resident is supervised by a licensed physician.Policy Interpretation and Implementation showed:1. A physician must recommend in writing that an individual be admitted to the facility. This can be accomplished through:a. hospital transfer summary completed by a physician;b. admission paperwork completed by the resident's physician in the community:c. other written form completed by a physician; ord. a physician 's admission orders for the resident's immediate care.2. Once a resident is admitted , orders for the resident's immediate care and needs can be provided by a physician, physician assistant (PA), nurse practitioner (NP), or clinical nurse specialist (CNS).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record reviews, the facility failed to investigate an injury of unknown origin, related to bruising on one resident (#3) of three sampled residents.Findings included: Review of the admission Record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses included but not limited to osteoarthritis of knee, disorders of brain, neutropenia, osteoarthritis of both knees, spondylosis without myelopathy or radiculopathy of the lumbar region, epilepsy, disc degeneration of lumbar region with back pain and anemia. Review of the current physician orders showed Aspirin 81 mg (milligrams) at bedtime for DVT (deep vein thrombosis) prophylaxis since 09/24/25Review of the Nursing PRN Skin Check dated 10/17/25 showed resident skin intact. No skin impairments noted at this time, full body check performed by this nurse with husband at bedside.Review of a nursing daily skilled note dated 10/13/25 showed skin was warm/dry. No surgical wound noted. No open wound noted.Review of a nursing daily skilled note dated 10/15/2 at 3:36 p.m. showed skin was warm/dry. No surgical wound noted. No open wound noted.Review of a Change in Condition (CIC) dated 10/15/25 at 11:00 p.m. showed the resident had a fall.Review of the progress note on 10/15/25 at 11:36 p.m. showed, this writer was notified by a staff member that this resident was on the floor. Upon my arrival, she was sitting upright, on the floor, between her bed and the window, trying to fold a blanket. She denied having any pain or hitting her head; however, because of her confusion and inability to describe in detail why she was on the floor, Neuro-checks have been initiated. Resident has full ROM (range of motion). Darker bruises on her upper thighs were present upon inspection, that appeared to be from prior falls.Review of the Nursing Daily Skilled Note dated 10/16/25, 10/17/25, 10/18/25, 10/19/25, 10/20/25, 10/21/25 and 10/22/25 showed the same note, Skin was warm/dry. No surgical wound noted. No open wound noted.Review of the care plan dated 09/29/25 showed Resident #3 was at risk for falls and / or fall related injury related to generalized weakness, limited endurance, impaired balance, unsteady gait, requires staff assist with transfers and ambulation, has a history of falls, has poor safety awareness as of 09/25/25, the resident is noted to have actual skin impairment, see wound notes and /or physician orders as of 09/29/25. Interventions included but not limited to observe skin impairment for signs and symptoms of infection and for significant decline: update physician if noted as of 09/29/25.A second focus in the same care plan showed - Resident has a potential for skin impairment related to impaired mobility, requires staff assist to turn and reposition, incontinence of bowel, incontinence of bladder, history of pressure ulcers, fragile skin, receives medication that may increase risk for bleeding and bruising as of 10/04/25. Interventions included but not limited to perform skin treatments as ordered as of 10/04/25. Observed skin for signs and symptoms of breakdown during care as of 10/04/25. Notify physician of any signs and symptoms of skin breakdown / pressure ulcer if noted as of 10/04/25.During an interview and observation on 10/23/25 at 10:00 a.m. Resident #3 was observed in their room. The therapy aide was with her. The resident did present any bruising on her thighs at the time. The aide stated she did not have any bruises, except she had bruising on her chest after a fall.During an interview and observation on 10/23/25 at 10:22 a.m. Resident #3 was observed in the dining room in her wheelchair. Resident #3 was noted to have 5 small areas of bruising, and tears on her left forearm. She stated it was from a bracelet she had on. Resident #3 stated she had not had any falls recently. During an interview on 10/23/25 at 1:06 p.m. Staff A, Licensed Practical Nurse (LPN) (agency staff) stated she took care of Resident #3 today. She stated Resident #3 was alert with confusion and a high fall risk. Staff A stated the report she received was Resident #3 had no changes. Staff A stated Resident #3 had not had any recent falls. Staff A stated Resident #3 was wheelchair bound. Staff A stated if a resident falls, the following should be done: assess the resident, assess for pain, check vital signs, do neuro checks, and check ROM (range of motion). Staff A stated the findings should be documented in the progress notes and facility form in the electronic chart. Staff A stated the neuro checks were in the electronic chart. She stated Resident #3 was currently not on neuro checks. Staff A stated the residents are supposed to have weekly skin checks that are done on their shower days. During an interview on 10/23/25 at 1:12 p.m. Staff B, Certified Nursing Assistant (CNA) stated Resident #3 was incontinent and required incontinent care, help with dressing, redirecting, coaching, and showers. Staff B stated she wakes Resident #3 up, takes her to the bathroom, brushes her teeth and wash her face. Staff B stated she takes Resident #3 out of the room to go to activities, therapy, bathroom, and the dining room. She stated Resident #3 was not on 1:1, but we keep an eye on her. Staff B, CNA stated Resident #3 has a bruise on her upper left hip the size of a fist. Staff B stated it had gotten smaller, since the first time she saw it. Staff B stated It was dark in color. Staff B stated Resident #3 has had it about 10-14 days. Staff B stated she thought she first saw the bruise on the resident the weekend before. During an interview on 10/23/25 at 1:15 p.m. Staff C, LPN stated if someone falls, they will assess them, do neuro checks, skin check, vital signs, pain assessment, and document on the facility internal form on the electronic chart. Staff C stated they will pick the resident up after the assessment. During an interview on 10/23 at 3:40 p.m. with the Director of Nursing (DON), the Assistant Director of Nursing (ADON) and the Regional Nurse Consultant (RNC), The DON stated Resident #3 was alert with confusion. The DON reviewing the Situation, Background, Assessment, Recommendation (SBAR) dated 09/27/25 stated, the resident slid out of the wheelchair. The DON stated they chart by exception at this facility. The DON stated they performed a skin check on the resident on 09/27/25 and it was okay. The DON and RNC reviewed the falls documentation for 09/27/25, 09/28/25, 09/29/25, 10/01/25, 10/06/25, 10/10/25, and 10/15/25. The DON and RNC reviewed the SBAR and progress note from 10/15/25 regarding a fall and the documentation which showed darker bruises on her upper thighs were present upon inspection, that appeared to be from prior falls. The DON stated she saw Resident #3 on 10/16/25 and the resident did not have any dark bruises. The resident had Petechiae (a small, pinpoint red or purple spot caused by bleeding under the skin surface). The DON said the resident had healing areas, not yellow. The DON stated she was not aware of any bruising. The RNC stated they do weekly skin checks around the shower days. The RNC stated the last skin check was performed on 10/17/25 per the electronic record. The RNC stated the skin check form should show anything new on the skin. The DON and RNC were informed regarding a bruise on the Resident #3s left hip. The DON stated the nursing administration team was unaware of this new area. The DON stated she would have to do an investigation. The DON and ADON left the interview to observe Resident #3's hip. The DON stated, when she returned to the interview, she looked at Resident #3 and the bruising Staff C, CNA, was talking about, and confirmed it was a new area. The DON stated this was new information to the nursing administration team and they would have to do a risk investigation. The DON stated Resident #3 had a dark bruise on her left hip about the side of a baseball. The DON and RNC stated they would have to follow a map and find out how it occurred. The DON confirmed she observed the 5 or 6 areas on Resident #3's left forearm and stated they would have to do an investigation about those also. The DON said, You would normally see it (bruising) reported and it would be investigated, and it would be on a skin sweep. The DON and RNC stated it should have been reported to the nurse who would have reported to the DON. The DON stated the skin sweep expectation was to perform them weekly. The DON confirmed they were not being done.During the interview on 10/23/25 at 5:07 p.m. Staff A, LPN stated she observed the bruise on Resident #3 today (with the DON and ADON). She stated it looked like an old bruise to her. She stated it was dark, red, black, purple bruised area about the size of a golf ball. She stated she did not measure it. She stated she was not aware of the bruise until the DON came down today to look at it.Review of the facility's policy, Change in a Resident's Condition or Status, revised February 2021, showed: - Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the residence medical /mental condition and / or status.Policy Interpretation and Implementation:1. The nurse will notify the resident's attending physician or physician on call when there has been an accident or incident involving the resident b. Discovery of injuries of an unknown source.2. A significant change of condition or a major decline or improvement in the resident's status that: a. will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions; b. impacts more than one area of the resident's health status; c. requires interdisciplinary review and/or revision to the care plan;3. Prior to notifying the physician or health care provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including information prompted by the Interact SBAR Communication Form.8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.Review of the facility's policy, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised April 2011 showed Residents have the right to be free from abuse, neglect, misappropriation of resident property and exportation. 8. Identify and investigate all possible incidents of abuse, and neglect, mistreat or misappropriation of resident property. 9e. Investigate and report any allegations within time frames required by federal regulations. 10. Protect residents from any further harm during investigations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews the failed to maintain a home-like environment for fourteen rooms (# 3, 4, 6, 8, 11, 14, 20, 32,33, 37, 48, 50, 54, 55, 62) out of fifty rooms sampled.Findings included: During a facility tour conducted throughout the facility starting at 10/15/2025 at 9:40 A.M., the following environmental concerns were observed:room [ROOM NUMBER] was observed with missing paint on the walls, and the bed had a reddish-yellowish-brown flaky coating of oxidizations on the metal frame. The same stained coloring was observed on the floors in the room.In room [ROOM NUMBER] the toilet was observed without sealant round the base of the toilet, missing paint from the frame of the bathroom door area, and the beds were with reddish-yellowish-brown flaky coating of oxidizations on the metal frame. One of the beds were noted with a broken side rail. One bedside table was observed with the edging detached from the table. room [ROOM NUMBER], was observed with holes in the wallsroom [ROOM NUMBER] was observed with black marks and missing board from off the wall.room [ROOM NUMBER] was observed with paint chipped off the bathroom door.room [ROOM NUMBER] was observed with unfinished work under the sink in the bathroom, toilet without sealant around the base of the toilet.Room # 37 was observed with missing paint and borders detached from the wall .Room numbers 3, 8, 11,37 48, and 50 were observed with baseboards detached from the walls.room [ROOM NUMBER] observed with missing paint in the bathroom and toilet paper stored on a plunger.room [ROOM NUMBER]'s air mattress cord was observed laying across the floor and going up the wall and plugged in to the Television.On 10/15/2025 at 2:00 p.m. an interview was conducted with the Director of Maintenance (DOM). The DOM said environmental concerns are brought to his attention when the staff puts the information in their work order system. He said he has access to the system on his phone, and he checks the system multiple times a day to see if there are any concerns. He said at this time he only had five open tasks to complete, and none of the issues were the concerns identified in rooms numbers (3, 4, 6, 8, 11,14, 20, 32, 33, 37, 48, 50, 54, 55, and 62). The DOM said this was the first time these concerns were brought to his attention. He said he stated he would also be informed about environmental concerns during morning meetings, but those rooms were never mentioned to him as having any environmental concerns. He said he would like to replace the beds in some of the rooms, but if he could not. He stated he would have to sand the beds down to remove the brownish oxidizations. The DOM said they were working on the holes in the walls using a patch and paint system, but have not gotten to some of the rooms yet. The DOM said they will have to wait until the residents are discharged from the rooms to make the repairs.On 10/15/2025 at 3:48 p.m., an interview was conducted with the Nursing Home Administrator (NHA). The NHA said he was notified of environmental concern during the morning meeting. The NHA stated the department heads make room rounds before the meeting every morning, then report any concerns they find in the meeting. He stated most of the time they make sure they put the concern in their work order system. The NHA said he also identifies concerns when he make his rounds in the facility. The NHA said nursing aides are o trained to report concerns in the work order system. The NHA said he would expect his staff to report any room lights that are out , electrical cords hanging from light fixtures, holes in the walls, any bed cords plugged in inappropriately, and other environmental concerns in the facility. He said when the staff bring concerns about beds with brown colored oxidization, he orders new ones. The NHA said staff should have brought the concerns to his attention.Review of the facility policy titled, Homelike Environment Revision date 02/2021, revealed policy statement: Resident are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belonging to the extent possible.Policy Interpretation and implementation: 2. The facility staff and management, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a clean, sanitary and orderly environment (Photographic Evidence Obtained)

Based on interviews and records review facility did not ensure residents received necessary prescribed medications upon admission for two residents (#1, #2) out of four residents reviewed. Findings included: 1.) An interview was conducted on 10/15/2025 at 10:06 a.m. with the resident representative (RR) for Resident #1. The RR said the resident had been discharged from the facility and was in the hospital for an issue with a foot wound. The RR said she had concerns about the facility not giving Resident #1 insulin when he was initially admitted to the facility. She said the resident finally received insulin, but only half of his normal dose. The RR said she had spoken to the nurse assigned to Resident #1 about her concerns. The RR said the resident also informed the nurse he was supposed to be on insulin his first day in the facility and asked about his insulin multiple times and filed a grievance.Review of admission Records showed Resident #1 was admitted from the hospital on 9/24/25 with diagnoses including type 2 diabetes mellitus with foot ulcer, type 2 diabetes with other specified complications, diabetes mellitus with diabetic peripheral angiopathy, and peripheral vascular disease.Review of Resident #1's Brief Interview for Mental Status (BIMS), completed 9/25/25, showed a score of 14, indicating he was cognitively intact.Review of Resident #1's hospital Medication Discharge Report, dated 9/24/25, showed, Stop Taking the Following Medications:-Insulin Aspart (Novolog Flex pen 100 units (u)/milliliter (ml) injectable solution. Sliding scale. Subcutaneous. Three times a day before meals.-Insulin Glargine (Lantus Solostar pen 100 u/ml subcutaneous injection. 20 u once a day.No additional medications for diabetic control were listed on the Medication Discharge Report.Review of Resident #1's Hospital Medication Administration Record (MAR) showed the resident last had Insulin Aspart 14 u on 9/24/25 at 6:01 p.m. and Insulin Glargine 10 u on 9/23/25 at 8:57 p.m.Review of Resident #1's progress notes did not show any documentation the discharge medication list was reviewed and reconciled with a provider upon admission.Review of Resident #1's weights and vitals showed no documentation the resident's blood glucose level was checked at the facility until 9/26/25 at 9:21 p.m., when the level reading was 240 milligram (mg)/deciliter (dL). (Normal range: fasting: 70-140 mg/dL; Post-meal: less than 160 mg/dL)Review of Grievance/Concern Reports showed a grievance filed by Resident #1 on 9/25/25 with concerns including the facility not having his medications at admission.Review of Resident #1's facility orders did not reveal any insulin orders as follows:-Novolog Flex Pen Subcutaneous Solution Pen-injector 100 u/ml (Insulin Aspart) Inject as per sliding scale: if 150 - 200 = 2 units give glucagon notify MD of BS <60; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units give 10 units and notify MD of BS > 400, subcutaneously before meals and at bedtime for diabetes mellitus (DM) type II for 7 Days. Start date 9/26/25.-Insulin Glargine Subcutaneous Solution. Inject 10 unit subcutaneously two times a day for diabetes mellitus. Start date 9/29/25. Review of Resident #1's facility MAR showed Novolog insulin was administered for the first time of 9/26/25 at 4:40 p.m. and the resident had a blood glucose level of 240 mg/dL, two days after admission to the facility. The MAR showed Insulin glargine was administered for the first time on 9/28/25 at 6:00 a.m., four days after admission to the facility.2.) An interview was conducted on 10/15/25 at 6:15 p.m. with the RR for Resident #2. The RR said when Resident #2 arrived at the facility it apparently wasn't clear in the hospital paperwork that the resident was on insulin. The RR said when the admitting nurse reviewed medication with them, they notified the nurse the resident needed insulin. The RR said Resident #2 went a day or so without insulin but didn't have any negative effects.Review of admission Records showed Resident #2 was admitted from the hospital on 9/27/25 with diagnoses including diabetes mellitus type II, chronic obstructive pulmonary disease, and obesity.Review of Resident #2's hospital paperwork did not list insulin on the Med Rec Discharge meds however, the Medication Discharge Summary from the hospital showed the resident was on Insulin, regular 70/30 100 u/ml 20 u twice daily before meals and Insulin Lispro 100 u/ml before meals and at bedtime.Review of Resident #2's progress notes did not show any documentation the discharge medication list was reviewed and reconciled with a provider upon admission.Review of Resident #2's orders did not show any orders for insulin put in at the facility upon admission.Review of Resident #2's Weights and Vitals Summary showed the resident's blood glucose level was not checked until 9/29/25 at 1:37 p.m., two days after admission to the facility, with a reading of 296 mg/dL.Review of Resident #2's facility orders and MAR showed an order for Novolin 70/30 flexpen 100 u/ml. Inject 45 u subcutaneously before meals related to type 2 DM, start date 9/29/25. The first dose was signed off as administered on 9/29/25 at 4:30 p.m. and the resident had a blood glucose level of 393 mg/dL. An order for Novolin 70/30 flexpen 100 u/ml. Inject 25 u subcutaneously at bedtime related to type 2 DM, start date 9/29/25. The first dose was signed off as administered on 9/29/25 at 9:00 p.m. The resident's blood glucose level was 397 mg/dL.An interview was conducted on 10/15/25 at 4:40 p.m. with Staff D, Licensed Practical Nurse (LPN). Staff D said when admitting a resident to the facility the resident came with a discharge medication list from the hospital, and the admitting nurse entered those orders into the facility orders. Staff D said the day after admission the supervisors reviewed the new admission and the orders. Staff D said the admitting nurse did not call the doctor or send the orders to the doctor to be reviewed. Staff D said when Resident #1 was admitted she was his assigned nurse but Staff E, Registered Nurse (RN) did his admission. She said she didn't recall seeing anything about Resident #1 being diabetic but did see that it said stop insulin. She said the resident's hospital paperwork was confusing. Staff D said a couple of days after admission she checked Resident #1's blood glucose and it was high so she called the provider and they gave an order for long acting insulin.An interview was conducted on 10/15/25 at 5:00 p.m. with Staff E, RN. He said when there is a new admission the resident came from the hospital with paperwork including their medication reconciliation. He said the admitting nurse entered the orders from the medication reconciliation into the computer. He said the nurse did not call and go over the medications with the provider. Staff E said usually the provider already knew the resident from the hospital anyway. He said the provider reviewed the medications when they came in and saw the resident. He said the providers are usually in the building twice a week. Staff E said if the admitting nurse had any questions, they could call the discharge nurse at the hospital or the provider. He said management also reviewed new admissions the next day. Staff E said if a resident came in on insulin or oral DM medications, they would put in an order for blood glucose checks to be done. Staff E said he did the admission for Resident #1. He said he wasn't concerned that the hospital medication reconciliation said to stop insulin because he had seen the hospital stop it for residents before at discharge. He said Resident #1 told him he was on insulin. Staff E said he had to show him the hospital paperwork where it said to stop taking insulin. He said he told the resident that is what he had to go by.An interview was conducted on 10/15/25 at 5:28 p.m. with the Director of Nursing (DON). She said when there is a new admission the facility would get some paperwork ahead of time, but the resident would also come with their discharge medication list from the hospital. The DON said the admitting nurse got the paperwork, did all the necessary evaluations and consents, go over medications with the resident and/or family, then call the doctor to get verification if medications are ok. The DON reviewed the records of Resident #1 and #2 and confirmed she did not see any documentation the admission medications were reconciled with a provider upon admission. She said she would expect there to be a nurses' note saying the provider was called and medications were reviewed. The DON said she expected the nurses to call the provider before putting orders into the computer for a resident. The DON said as far as blood glucose checks she said there were batch orders that everyone can have a blood glucose check for signs or symptoms of high or low blood sugar. She said if a resident says they are diabetic the nurse should do blood glucose checks. The DON said for Resident #1 the fact he wasn't getting insulin was brought to the facility's attention when the resident filed a grievance. She said she would have expected the nurse to call the doctor if a resident told them they should have insulin and were not getting it. The DON said regarding Resident #2, just because she is diabetic doesn't mean she would get insulin or need blood glucose checks. She said it was concerning that nurses were not calling the provider to reconcile medications on admission. The DON said the facility did have an admission checklist, but it depended on the nurse if they used it or not.A follow-up interview was conducted with the DON on 10/15/25 at 6:45 p.m. The DON said the day after a resident's admission the resident is reviewed in the morning clinical meeting. She said they ensure everything is in the record and match what came from the hospital. The DON said she was not there when Resident #1 and #2's records would have been reviewed, and the clinical team didn't remember if they reviewed them.An interview was conducted on 10/15/25 at 6:48 p.m. with the Assistant Director of Nursing (ADON). She said when reviewing new admission in the clinical meetings the Unit Manager (UM) reviewed the admission paperwork and the resident's electronic medical record if pulled up on the big screen. She said the UM goes through the paperwork from the hospital and they all make sure the orders were entered correctly. She did not recall if Resident #1 and #2's records were reviewed.An interview was conducted on 10/15/25 at 6:55 p.m. with Staff F, LPN/UM. Staff F said she did admission record reviews and in that process, she made sure batch orders were in place, she checked medications on the discharge paperwork and ensured correct doses were ordered. Staff F said she did not recall Resident #1 or #2's review. She said seeing stop insulin on the hospital discharge paperwork wouldn't necessarily make her question it because some residents are on insulin temporarily in the hospital, but if a resident and/or RR said the resident was on insulin she would call the doctor or expect the nurse to call and get orders for insulin and/or blood glucose checks.Residents #1 and #2 primary care provider could not be reached.Review of the facility admission Checklist included but not limited to: -Add/Verify Attending Physician-Input Diagnosis and review H&P (history and physical)-Review hospital discharge orders-Add/Verify MD (medical doctor) orders from discharge med reconciliation ensure appropriate diagnosis, route, parameters. Ensure each diagnosis is covered in medication regimen if applicable.On 10/15/25 at 7:04 p.m. the DON stated the facility did not have a policy on medication reconciliation or diabetes management or the admission process.Review of a facility job description titled Licensed Practical Nurse/Registered Nurse, revised 1/1/15, showed: Purpose of Your Position - The primary purpose of your position is to provide direct nursing care to the residents, and to supervise the day-to-day nursing activities performed by CNAs/GNAs and other nursing personnel. To monitor the performance of CNAs/GNAs, nursing and non licensed personnel, provide education and counseling, perform disciplinary action as necessary, and complete performance evaluations. Such supervision must be in accordance with current federal, state, and local standards, guidelines, and regulations that govern our Facility, and as may be required by the Director of Nursing Services or Nurse Supervisor to ensure that the highest degree of quality care is maintained at all times.Charting and Documentation Complete and file required recordkeeping forms or charts upon the resident's admission, transfer, and/or discharge. Encourage attending physicians to review treatment plans, record and sign their orders, progress notes, etc., in accordance with established policies. Receive telephone orders from physicians and record on the Physician's Order Form.Transcribe physician's orders to resident charts, cardex, medication cards, treatment or care plans, as required. Chart nurses' notes in an informative and descriptive manner that reflects the care provided to the resident, as well as the resident's response to the care. Report all discrepancies noted concerning physician's orders, diet change, charting error, etc., to the Nurse Supervisor and/or Unit Manger.Drug Administration Functions Review medication cards for completeness of information,) accuracy in the transcription of the physician's order, and adherence to stop order policies. Notify the attending physician of automatic/stop/orders prior' to the last dosage being administered.Nursing Care Functions Consult with the resident's physician in providing the resident's care, treatment, rehabilitation, etc., as necessary. Review the resident's chart for specific treatments, medication orders, diets, etc., as necessary. Maintain established nursing objectives and standards.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to ensure referral for urology consultation/evaluation was provided for one resident (#5) of three residents sampled.Findings Included: Review of an admission Record dated 10/23/2025 revealed Resident #5 was admitted to the facility on [DATE] with diagnoses to include but not limited to Type 2 Diabetes Mellitus with hyperglycemia, neuromuscular dysfunction of bladder, unspecified, infection and inflammatory reaction due to indwelling urethral catheter, subsequent encounter, chronic kidney disease, stage 3A. Review of an order summary dated 10/23/2025 showed:Consult Urology for urinary retention, verbal active order, dated 10/23/2025. Review of a progress note dated 10/08/2025 created by Staff G, Advanced Registered Nurse Practitioner (ARNP) noted to start a voiding trial on Resident #5. If voiding trial fails reinsert indwelling foley and consult urology. Review of a progress note dated 10/13/2025 created by Staff G, ARNP showed Staff G gave verbal orders previously on Friday for voiding trial, but it was not done for unknow reasons. Staff G noted she spoke with nursing and the Director of Nurses (DON) about the plan and requested voiding trial to be done and if voiding trial fails, consult urology. Review of a progress note dated 10/20/2205 created by Staff G, ARNP showed on 10/20/2025, Resident #5 did not pass voiding trial despite electronic record documentation indicating otherwise. Staff G noted Resident #5 had not voided with need for straight cath (catheterization) and greater than 400 mls [milliliters] output with urinalysis with culture and sensitivity obtained and + yeast, see labs and plan. On 10/23/2025 at 2:00 p.m. an interview was conducted with the Director of Nurses, DON. The DON said the ARNP put Resident #5 on a voiding trial because she did not have justification for the use of a foley catheter. The DON stated the ARNP wanted Resident #5 to start a voiding trial. The DON said, When we conducted the trial, the resident failed. The DON said the Nurse Practitioner noted to consult urology if Resident #5 failed the trial, but she did not put an order in the system. The DON said when she reached out to the ARNP she told them to just leave the foley in. The DON said the ARNP could have put the urology consult order in the system if she wanted Resident #5 to be seen by urology. On 10/23/2025 at 3:30 p.m. an interview was conducted with Staff G, ARNP. The ARNP said she wrote in her progress notes to start a voiding trial on Resident #5 because she had a diagnosis on her 3008 for acute retention. She said she told the nurse and the director of nurses twice if the resident failed the voiding trial to consult urology. She said the director of nurses reached out to tell her the resident was not voiding, and they only obtained 2000 milliliters of urine. The ARNP said she told the DON they needed to get a consultation from urology. The ARNP said once she gave the facility a verbal order they should have put the urology consult order in the system. She said she told the Unit Manager and the DON both to consult urology if the resident did not pass the voiding trial. She said the told the Unit Manager on Friday and told the DON again on Monday to consult urology for Resident #5. She said she told them to leave the foley in and consult urology The facility did not have a policy/procedure regarding care consultation and referral.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to complete the Pre-admission Screening and Resident Review (PASRR) Level II upon a new qualifying mental health diagnoses and failed to resubmit for a PASRR Level II review for five residents (Resident #1, Resident #3, Resident #98, Resident #46, and Resident #38) of 10 residents sampled for PASRRs.
Findings included:
1.
Review of Resident #1's admission Record revealed an original admission date of 8/5/09 and a readmission date of 12/17/22. Review showed the resident had the following diagnoses listed:
- Schizoaffective disorder, bipolar type dated 1/24/24.
- Unspecified dementia, unspecified severity, with psychotic disturbance dated 5/11/23.
- Epilepsy, unspecified, not intractable, without status epilepticus dated 10/14/15.
- Major depressive disorder, single episode, unspecified dated 10/1/15.
- Unspecified mood [affective] disorder dated 10/1/15.
- Anxiety disorder, unspecified dated 09/10/15.
- Unspecified intellectual disabilities dated 12/17/22.
Review of a Level II PASRR Determination Summary Report dated 7/20/09 showed the resident was reviewed related to history of seizure disorder, reported history of mild schizophrenia, depression and impulse control. The review did not include the newly acquired diagnoses. he review showed a Level II PASRR was not submitted for recommendation.
3.
Review of Resident #46's admission Record revealed Resident #46 was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Review showed the resident had the following diagnoses listed:
- Adjustment disorder with depressed mood dated 3/24/24.
- Generalized anxiety disorder dated 9/25/20.
- Schizoaffective disorder dated 4/13/20.
- Major depressive disorder dated 7/29/20.
Review of Resident #46's PASRR Level II Determination Summary Report dated 3/13/2019 revealed, Resident #46 meets the definition of Serious Mental Illness.
Review of Resident #46's medical record did not reveal an updated PASRR Level II after identification of new diagnoses.
Review of Resident #38's admission Record revealed Resident #38 was admitted to the facility on [DATE] and readmitted on [DATE]. Review showed the resident had the following diagnoses listed:
- Major depressive disorder, recurrent, severe with psychotic symptoms dated 9/10/20.
- Anxiety disorder, unspecified dated 9/10/20.
- Unspecified mental disorder due to known physiological conditions dated 9/10/20.
- Unspecified psychosis not due to a substance or known physiological condition dated 9/10/20.
- Unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety dated 6/3/16.
Review of Resident #38's PASRR Level II Determination Summary Report dated 1/20/2022 revealed Resident #38 meets the definition of Serious Mental Illness.
Review of Resident #38's medical record did not reveal an updated PASRR Level II after a identification of new diagnoses.
An interview was conducted on 12/18/24 at 1:44 p.m. with the Social Services Director (SSD). The SSD said after admission to the facility, she meets with the nursing leadership team to review the resident's PASRR and their diagnoses to determine if a Level II PASRR evaluation is required. The SSD acknowledged the PASRRs were not updated upon acquiring new diagnoses and Level II PASRRs should have been completed.
Review of the facility policy and procedure titled Resident Assessment - Coordination - Pre-admission Screening and Resident Review (PASRR) program, not dated, revealed under Intent, it is the policy of the facility to assure that all residents admitted to the facility receive a PASRR, in accordance with state and federal regulations. The policy also revealed the following Procedure:
2. Coordination includes:
a. Incorporating the recommendations from the PASRR level Il determination and the PASRR evaluation report into a resident's assessment, care planning, and transitions of care.
b. Referring all level Il residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level Il resident review upon a significant change in status assessment.
2.
Review of Resident #3's admission Record showed Resident #3 was admitted to the facility on [DATE]. Review showed the resident had the following diagnoses listed:
- Generalized anxiety disorder dated 5/31/24.
- Unspecified dementia, unspecified severity, with psychotic disturbance dated 5/11/23.
Review of the Level I PASRR, dated 8/14/2024 showed in Section II: Other Indications for PASRR Screen Decision-Making, questions 1 through 7 were marked No. A Level II PASRR evaluation must be completed if the individual has a primary or secondary diagnosis of dementia or related neurocognitive disorder (including Alzheimer's disease). Section IV: PASRR Screen Completion,
Individual may be admitted to a Nursing Facility (check one of the following): No diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASRR evaluation not required was marked.
Review of Resident #98's admission Record showed Resident #98 was admitted to the facility on [DATE]. Review showed the resident had the following diagnoses listed:
- Generalized anxiety disorder dated 11/6/24.
- Unspecified dementia, unspecified severity, with mood disturbance dated 11/6/24.
- Depression, Unspecified dated 10/30/24.
Review of the Level I PASRR, dated 11/5/2024 showed in Section II: Other Indications for PASRR Screen Decision-Making, questions 1 through 7 were marked No. A level II PASRR evaluation must be completed if the individual has a primary or secondary diagnosis of dementia or related neurocognitive disorder (including Alzheimer's disease). Section IV: PASRR Screen Completion, Individual may be admitted to a Nursing Facility (check one of the following): No diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASRR evaluation not required was marked.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to complete the Pre-admission Screening and Resident Reviews (PASRR) for residents with a mental disorder and individuals with intellectual disability following identification of qualifying mental health diagnoses for three residents (Resident #36, Resident #102, and Resident #53) of 10 residents sampled for PASRRs.
Findings included:
Review of Resident #36's admission Record revealed an admission date of 5/2/24. Review showed the resident had newly acquired diagnoses of major depressive disorder, dated 9/10/24 and Alzheimer's disease, dated 5/3/24.
Review of a Level I PASRR for Resident #36 dated 5/3/24 revealed a blank PASARR and the qualifying diagnoses were not checked.
Review of admission Records showed Resident #102 was admitted on [DATE] with diagnoses including bipolar disorder, generalized anxiety disorder, adjustment disorder with anxiety, major depressive disorder, and mood (affective) disorder.
Review of Resident #102's PASRR Level I Screen, dated 4/25/24, did not indicate the resident had a diagnosis of any mental illness or suspected mental illness.
An interview was conducted on 12/18/24 at 1:44 p.m. with the Social Services Director (SSD). The SSD said after admission to the facility, she meets with the nursing leadership team to review the resident's PASRR and their diagnoses to determine if a Level II PASRR evaluation is required. The SSD acknowledged the PASRRs were not updated upon acquiring new diagnoses.
Review of the facility policy and procedure for Resident Assessment - Coordination - Pre-admission Screening and Resident Review (PASRR) program, not dated, revealed under Intent, it is the policy of the facility to assure that all residents admitted to the facility receive a Pre-admission Screening and Resident Review, in accordance with State and Federal Regulations. The policy also revealed the following Procedure:
1. The facility will coordinate assessments with the pre-admission screening and resident review (PASRR) program under Medicaid in subpart C of this part to the maximum extent practicable to avoid duplicative testing and effort.
2. Coordination includes:
a. Incorporating the recommendations from the PASRR level Il determination and the PASRR evaluation report into a resident's assessment, care planning, and transitions of care.
b. Referring all level Il residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level Il resident review upon a significant change in status assessment.
3. Preadmission Screening for individuals with a mental disorder and individuals with intellectual disability. The facility will not admit, on or after January 1, 1989, any new residents with:
a. Mental disorder, unless the State mental health authority has determined, based on an independent physical and mental evaluation performed by a person or entity other than the State mental health authority, prior to admission:
i. That, because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility; and ii. If the individual requires such level of services, whether the individual requires specialized services for mental retardation.
Review of Resident #53's admission Record showed she was admitted to the facility on [DATE] with diagnoses to include major depressive disorder and generalized anxiety disorder.
Review of Resident #53's Level I PASRR, dated 9/9/2022 showed in Section I: PASRR Screen Decision-Making: A. MI or suspected MI (check all that apply), Schizophrenia is marked. Anxiety Disorder and Depressive disorder was not marked.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure treatment and care for chronic conditions were provided in accordance with professional standards of practice and failed to complete timely and thorough assessments for one resident (Resident #36) of one resident reviewed for edema.
Findings included:
On 12/16/24 at 9:38 a.m., Resident #36 was observed in the dining room during a morning activity session sitting in her wheelchair. The resident was noted with swelling in both of her lower legs.
Review of Resident #36's admission Record showed the resident was admitted to the facility on [DATE]. The review also revealed the resident had a newly acquired diagnosis of edema, unspecified, dated 11/7/24.
Review of Resident #36's medical record revealed the following:
- The Medical Certification For Medicaid Long-Term Care Services and Patient Transfer Form dated 5/2/24 did not show a documented edema diagnosis.
- Review of an admission History and Physical (H&P) dated 3/11/24 did not show a diagnosis of edema.
A review of Resident #36's admission nursing comprehensive evaluation dated 9/10/24 showed the resident had suspected deep tissue injury to her left heel and sacrum but no other skin conditions were documented.
Review of physician notes for Resident #36 showed from 7/31/24 to 9/17/24, there were no documented concerns related to edema diagnosis. The notes showed, skin is unremarkable with no worrisome lesions seen, color is good. No jaundice or cyanosis seen.
Review of a CIC (Change in Condition) SBAR (Situation, Background, Assessment, Recommendation) Communication Form dated 10/31/24 showed Resident #36 had +3 edema to LLE (left lower extremity). There were no additional notes related to this change.
Review of a physician note dated 11/1/24 showed the PCP ordered an ultrasound of left lower extremity secondary to edema.
Review of Resident #36's Radiology Results Report dated 11/1/24 showed the following:
- Procedure: left duplex scan, veins, extremity, unilateral /limited study
- Findings: technique: Real-time ultrasonography of the left lower extremity venous vasculature was performed, and static images are presented for interpretation.
- Findings: the left common femoral and left proximal to mid superficial femoral veins were visualized and are noncompressible.
- Impressions: Acute, deep venous thrombosis involving the left common femoral and left proximal to mid superficial femoral veins.
A nursing progress note dated 11/1/24 showed an order note for Eliquis (Apixaban) oral tablet 5 mg (milligrams) mg give 1 tablet by mouth two times a day for DVT (deep vein thrombosis).
Review of active physician orders dated 12/18/24 showed the Apixaban was ordered on 11/1/24 and started on 11/9/24. Review of Resident #36's physician orders also showed furosemide (Lasix) oral tablet 20 mg, give 1 tablet by mouth one time a day for edema, initiated on 11/16/24.
Review of Resident #36's Minimum Data Set (MDS) assessment dated [DATE] under Section I - Active Diagnoses did not show the diagnosis of chronic edema.
On 12/17/24 at 2:16 p.m. an interview was conducted with the Director of Nursing (DON). She stated Resident #36 was seen by her Primary Care Physician (PCP) earlier that day. The DON stated the original Change in Condition (CIC) was discovered on 11/7/24 and, The doctor stated there wasn't much that can be done. Her edema is chronic. We can ask her to elevate her legs as much as possible. The DON stated the resident could not get footrests to elevate her legs because she ambulates independently, and the resident was receiving Lasix.
Review of an ARNP (Advanced Registered Nurse Practitioner) note dated 11/5/24 and electronically signed by the ARNP on 12/17/24 at 3:26 p.m., showed Patient has a positive DVT (Deep Vein Thrombosis) to the left common femoral and left proximal to mid superficial femoral veins. Spoke with nursing.
Review of an Update Diagnosis note for Resident #36 dated 12/17/24, and with a revision date of 12/18/24, showed under Description: Localized Edema, Date: 5/2/24, Classification: During Stay, Comments: Chronic.
Review of Resident #36's care plan initiated 5/17/24 showed, the resident has a potential for skin impairment/pressure ulcers related to impaired mobility, requires staff assist to turn and reposition, incontinence of bowel, incontinence of bladder, fragile skin, has a cachectic appearance, and receives steroids. On 12/17/24, the care plan was revised to include, chronic edema to BLE [Bilateral Lower Extremities].
Review of Resident #36's nursing progress notes dated from 11/1/24 to 12/7/24 revealed inconsistent monitoring and documentation of the resident's condition as follows:
- 11/1/24: Edema noted to LLE.
- 11/2/24: Edema present: Has edema in the following extremities: LLE non-pitting.
- 11/3/24: Edema present: Has edema in the following extremities: LLE non-pitting.
- 12/17/24: Resident noted with 1+pitting edema to BLE (bilateral lower extremities).
During an observation and interview on 12/18/24 at 2:02 p.m., Resident #36 was observed with swelling in both feet. Her right leg was observed more swollen than the left and the legs were mottled on the lower end of both feet. The resident stated sometimes it hurts. During the interview Staff A, Registered Nurse (RN), assigned to this resident, stated the resident had chronic edema and has had swelling to both feet, which started about 6 weeks ago. She stated when the swelling started increasing to her left foot, the resident was prescribed Lasix. Staff A, RN stated the expectation for nursing is to document in the skilled notes their daily assessment of the resident's condition, especially when there has been a change. This nurse stated sometimes this resident complains of pain, mostly during the day because she is mobile, and does not want to sit or put her feet up. She stated they should be documenting the appearance of her feet and any changes noted.
On 12/19/24 at 11:30 a.m., an interview was conducted with Staff D, RN/MDS Coordinator. She stated to complete a care plan, they look at diagnosis, review orders, and history and physical. She confirmed diagnosis of edema should be listed in Section I of the MDS Assessment if the diagnosis was present on admission. Staff D, RN MDS also stated Resident #36 did not have the diagnosis when the MDS Assessment was done and if nurse's notes and wound care notes showed the concern, it would be documented, and the care plan would be updated with the skin condition of edema. Staff D, RN/MDS confirmed the care plan was not updated because they did not know she had that problem. Staff D, RN/MDS also confirmed the care plan was edited on 12/17/24 and she did not see the edema diagnosis on the Medical Certification For Medicaid Long-Term Care Services and Patient Transfer Form or the H&P.
On 12/17/24 at 03:48 p.m., an interview was conducted with Staff B, Licensed Practical Nurse (LPN). She stated she worked with Resident #36 often and approximately 2 weeks ago, the resident had shown signs of edema due to a DVT and was prescribed Lasix. She stated if a resident was diagnosed with edema, they would monitor the resident daily, checking pedal pulses, swelling, and signs of infection. She also stated there should be daily skilled notes to show nursing interventions, such cueing the resident to elevate their feet. She stated she did not know if she had documented on this particular resident, and she was reminded today during change of shift to monitor the resident.
On 12/18/24 at 2:06 p.m., an interview was conducted with Staff C, RN/Unit Manager. She stated Resident #36 had chronic edema issues. She stated she remembered seeing that information documented somewhere, but she could not find it at the moment. She stated on 11/1/24 the resident was noted with a DVT. She revealed two progress notes dated 11/2/24 and 11/3/24 documenting the resident's edema assessments, but no other notes. This nurse confirmed she did not see any other nurses notes and could not confirm if the resident had edema on her left, right, or both legs. She stated nurses should be documenting in the skilled notes of observations of their monitoring of the resident's condition.
On 12/19/24 at 9:45 a.m., an interview was conducted with the DON. She said, [Resident #36] had edema before, even prior to 11/1/24. It was documented in May that she had edema in the hospital. That is why we say it is chronic edema. The DON stated there were a couple nurse's notes on 11/1/24, 11/2/24 and 11/16/24. She stated on 11/1/24, the nurse noted her legs were swollen and called the resident's PCP and the resident was diagnosed with DVT, and orders were put in place. The DON stated the resident was prescribed Eliquis. She also stated another nurse documented a CIC new or worsening edema on 11/16/24 and noted bilateral 2+. The DON stated the nurses would not document unless the condition was acute and confirmed the diagnosis of DVT was new. The DON stated there was no documentation of monitoring for worsening or improvement or to identify if the left leg is pitted more than the right. She said, I can see how we need education on documentation. There is no specific monitoring of pitting. I can see need for education on assessments, how to document pitting or non-pitting. We should work on identifying a baseline. However, this resident fluctuates a lot depending on her activities.
On 12/19/24 at 10:21 a.m., an interview was conducted with Resident #36's PCP. He stated this resident was seen at least monthly, most recently 12/7/24, and on 11/7/24. He also stated he saw the resident at least bi-weekly, but it was not always documented. He said, I regularly check-up her edema. I have given her instructions to elevate her feet. The PCP stated Resident #36 was started on a low dose Lasix and her edema had been chronic for years. He stated it was mostly a +2, dependent edema. The PCP stated the resident was older and she would not tolerate compression stockings or consistent elevating, and her symptoms change depending on activity, such as first thing in the morning she has almost none, but by the afternoon she is pitting. The PCP stated he monitored and documented once a month. The PCP stated related to nursing documentation, It is not realistic to document daily but, if there is a change out of her normal, I should be notified. He stated he should be notified if there was a change related to the DVT, I'd expect them to monitor. I'd be worried about breathing, worsening edema, infection or pain.
Review of a facility policy titled Charting and Documentation, revised July 2017, showed under Policy Statement, all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. The policy also showed the following under Policy and Interpretation:
1. Documentation in the medical record may be electronic, manual or a combination.
2. The following information is to be documented in the resident medical record:
a. Objective observations.
b. Medications administered.
c. Treatments or services performed.
d. Changes in the resident's condition.
e. Events, incidents or accidents involving the resident; and
f. Progress toward or changes in the care plan goals and objectives.
7. Documentation of procedures and treatments will include care-specific details, including:
b. The name and title of the individual(s) who provided the care; the assessment data and/or any unusual findings obtained during the procedure/treatment.
Review of a facility policy titled Change in a Resident's Condition or Status, revised February 2021, showed, the nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.
During a facility tour of Zone 3 on 12/16/24 at 9:44 a.m. environmental concerns were identified in rooms #1, #2, #3, #4, and #5. The room walls were observed to have holes, chipped paint, stains, and damaged baseboards. room [ROOM NUMBER] was observed with stained toilet base caulking with brown colored matter.
On 12/17/24 at 3:45 p.m. and on 12/18/24 at 9:28 a.m., the previously identified environmental concerns were observed in resident rooms #1, #2, #3, #4, and #5.
On 12/18/24 at 9:32 a.m. an interview was conducted with Staff F, Housekeeping. He stated if he observed a room in disrepair or stained toilet bases that were not cleanable, he would report it to maintenance. He said, I would tell the nurse to put it into [name of work orders management system].
On 12/19/24 at 12:42 p.m. an interview was conducted with the Director of Maintenance (DOM). He confirmed he was aware the facility had damaged walls and baseboards in some of the rooms. He said, We have been tearing down walls, removing the trim, and adding new baseboards. The DOM stated some resident rooms needed to be repaired and the resident rooms were on the schedule to be repaired, but he was waiting for the census to go down. The DOM also stated if any employee saw items that needed to be repaired or replaced, they should put it into the facility's work orders management system. He said, If the toilet bases are not cleanable, they should be scheduled for us to strip and re-caulk. The DOM presented the list of current open work orders. The rooms noted with concerns were not documented in their system for pending repairs.
Review of the facility policy titled Maintenance Service, revised December 2009, revealed the following:
Policy Statement: Maintenance service shall be provided to all areas of the building, grounds, and equipment.
Policy Interpretation and Implementation:
1. The maintenance department is responsible for maintaining the buildings, grounds, and equipment a safe and operable manner at all times.
2. Functions of maintenance personnel include, but are not limited to:
a. maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines.
b. maintaining the building in good repair and free from hazards.
c. maintaining the fire alarm system and emergency generator system in good working order.
d. maintaining the heat/cooling system, plumbing fixtures, wiring, etc., in good working order.
e. maintaining lighting levels that are comfortable and assuring that exit lights are in good working order.
f. establishing priorities in providing repair service.
g. maintaining the paging system in good working order.
h. maintaining the grounds, sidewalks, parking lots, etc., in good order.
i. providing routinely scheduled maintenance service to all areas.
j. others that may become necessary or appropriate.
3. The maintenance director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner.
(Photographic Evidence Obtained)
Based on observations, interviews, and policy review, the facility failed to ensure resident rooms were maintained in a safe, sanitary, and homelike manner in three Zones (Zones 3, 6, and 8) out of eight facility Zones.
Findings included:
1.
During a facility tour of Zone 6/8 on 12/16/24 10:58 a.m. the following observations were made:
- The nursing station front was covered in a textured paper, the paper had white and black stains, and a piece of trim was being held on by silver tape.
- The bathroom connected to room [ROOM NUMBER] was observed to have a black ring of dirt and debris around the base of the toilet, with no caulking. The call light cord and the wall in the bathroom was also splattered with a brown substance.
- In room [ROOM NUMBER], the wall, baseboard, and floor had dried liquid splattered on them. The door bed had a brown substance on the footboard.
- The bathroom connected to room [ROOM NUMBER] was observed to have black marks and stains on the floor, a black ring, and cracked caulk around the base of the toilet. The widow bed had dirt, dust, hair, and debris on the bed frame and side rails. The baseboards were observed coming off the wall.
- In room [ROOM NUMBER], the outlet cover on the wall next to the sink was cracked. The walls near the sink and the door to the room had previous drywall patches that were not painted and were cracked and coming apart. Above the window bed, there was a large stain on the ceiling, the texture was missing, and the drywall paper was peeling. The resident in the room said the stain had been there for a few months. She said the wall behind her bed was messed up as well and she wished her room was better. The wall behind the bed was observed to have a hole where a section of board was missing and the wall behind it was crumbling.
During a follow-up tour on 12/19/24, the observations remained unchanged. room [ROOM NUMBER] was also observed to have a different resident in the door bed, however the brown substance remained on the footboard.
An interview was conducted on 12/19/24 at 3:21 p.m. with the Regional Environmental Services (EVS) Director. She said when a resident moves out of a room the mattress is taken off the bed and the bed frame is cleaned. She said every room should get cleaned daily and deep cleaned once a month. She stated if a bed frame was visibly dirty it should have been cleaned. The Regional EVS Director was observed going to room [ROOM NUMBER] and looking at the foot board. She said, I could wipe that off right now. She said there is nothing she can say about it not being cleaned from one resident to the next. She said the bed should have been cleaned, especially during a terminal clean. She also stated any staff members, including nurses or certified nursing assistants (CNAs) that observed the brown substance on the bed should have cleaned it off. She said they all work together as a team. The Regional EVS Director was observed going to room [ROOM NUMBER] and looking at the window bed. She said the bed should have been cleaned on the monthly deep cleaning. The Regional EVS Director reviewed the deep cleaning schedule and said it appeared room [ROOM NUMBER] had not been deep cleaned since October. She stated room [ROOM NUMBER] had been scheduled to be deep cleaned on 12/17/24 but it did not appear to be done.
An interview was conducted on 12/19/24 at 5:06 p.m. with the Director of Nursing (DON). She reviewed photographic evidence taken of the bed in room [ROOM NUMBER]. She said she would have expected staff to clean the brown substance off of the bed and she was surprised it remained even after the change of residents in the bed. She said the facility also had an ambassador program where management is assigned to do rounds, and she would have expected that to have been seen and cleaned.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and policy review, the facility failed to ensure a written Notice of Transfer and/or Discharge Notice was issued in writing for one resident (Resident #94) of three residents reviewed for transfer/discharge process and failed to ensure a thirty (30) day Notice of Discharge was provided one resident (Resident #94) of three residents reviewed for transfer/discharge process.
Findings included:
Review of Resident #94's admission Record showed Resident # 94 was admitted to the facility on [DATE].
Review of Resident # 94's Consent to Treat, dated 10/19/24, revealed verbal consent for treatment was received from Resident #94's Emergency Contact.
Review of Resident #94's Brief Interview for Mental Status (BIMS) Assessment, dated 10/19/24, showed a BIMS score of 6/15, indicating severe cognitive impairment and impaired insight and judgement.
Review of Resident # 94's Social Services Notes, dated 10/21/24 at 3:03 PM, revealed Resident #94's memory is impaired related to cognitive deficit.
Review of Resident #94's Minimum Data Set (MDS) assessment dated [DATE] showed under Section Q - Participation in Assessment and Goal Setting, the overall goal for discharge was to remain in the facility, with the information source documented as family.
Review of Resident #94's Psychiatry Provider Physician Assistant (PA) note, dated 10/23/24, revealed the following: impaired cognition, impaired short-term memory, fair to impaired long-term memory, and impaired judgement. Resident #94 was diagnosed with dementia. The Dementia Functional Assessment Staging Test (FAST) revealed Resident #94 has stage 5 dementia.
Review of Resident #94's Speech Therapy evaluation and plan of treatment note dated 10/24/24 revealed a St. Louis University Mental Status (SLUM) exam score of 10 out of 30, indicating cognitive deficits.
Review of an Elder Affairs of Florida Notification of Level of Care dated 11/1/24, showed recommendations for a skilled level of care and placement in a Nursing Home.
Review of Resident #94's Progress Notes dated 12/7/24 at 11:22 PM, revealed at approximately 6:15 PM, Resident #94 was standing at another resident's bedside and both residents were yelling at each other. Resident # 94 was placed on one-to-one monitoring following the incident.
Review of Resident #94's Psychiatry Provider evaluation note dated 12/9/24, revealed Resident #94 had a history of dementia and recommendations included psychotropic medication management and assessment. Resident stated to the provider, I am being ping-ponged back-and-forth and confirmed feeling agitated. The note also revealed Resident #94 will be evaluated by another facility .today .for potential discharge. The note revealed Resident #94's thought process is organized with confusion, short term and long-term memory are fair to impaired and staff were educated to offer non-pharmacological interventions including redirection and reassurance.
Review of Resident #94's Progress Notes dated 12/10/24 at 11:57 AM revealed resident discharged to other facility.
Review of Resident #94's Nursing Home Transfer and Discharge Notice revealed the notice was given on 12/10/24. The Notice revealed under Reason for Discharge or Transfer was Your needs cannot be met at this facility. The section of the form titled Notice received by, was blank and did not document the name of the person receiving the notice or a signature of the person receiving the notice.
Review of Resident #94's medical record did not contain documentation indicating Resident #94 received advance notice of discharge, no documentation of Resident #94's voiced intent of transfer, nor was there documentation of the facility's attempts to meet the resident's needs or what services the new receiving facility had in order to meet the resident's needs that were not available at the current facility.
During an interview on 12/18/24 at 11:20 AM with Resident #94's Psychiatric Physician Assistant (PPA), the PPA stated there were two incidents' of behaviors displayed by Resident #94, one involved another resident and the second involved a nurse. The PPA said Resident #94 was confused and on all accounts had a good rapport with staff. She said increased incidents in Resident # 94's behaviors may have been related to miscommunication and how staff approached him and he may do well in a memory unit.
During an interview on 12/18/24 at 12:19 PM with the facility's Director of Nursing (DON) and the Social Services Director (SSD), the SSD said Resident # 94 was transferred to another facility because the facility was at capacity, and they found a facility to accept him.
During an interview on 12/18/24 at 5:24 PM, the SSD confirmed Resident # 94's discharge was a facility-initiated discharge and discharge notification was provided to the resident on 12/10/24.
During a telephone interview on 12/18/24 at 7:54 PM, Resident # 94's Emergency Contact (EC), the EC said he had not been notified of Resident #94's transfer to another facility. He also said a 30-day discharge notification didn't happen. The EC said the nurse called and told him Resident #94 was blocking the door with his wheelchair; I don't know if that caused them to push him out of the nursing home. The EC also said the last time he spoke with Resident #94, the resident thought Regan was president, and it was 1994.
During an interview on 12/19/24 at 12:07 PM, with Staff E, Nursing Consultant (NC), Staff E, NC said Resident #94 received a 30-day discharge notice on the day of discharge, 12/10/24. Staff E, NC also stated a 30-day discharge notice could be given at any time.
During a follow up interview on 12/19/24 at 5:08 P.M., with the NHA, DON, SSD, and Staff E, NC, the SSD said there were fluctuations in Resident #94's cognition, and he was more lucid at times. Staff E, NC said Resident #94 was transferred to another nursing home that has more psychiatric services. Staff E, NC also stated onsite psych services were available more days a week at Resident #94's new facility.
Review of the facility policy titled Transfer or Discharge Notice, revised March 2021, revealed the Policy Statement: Residents and/or representatives are notified in writing, and in a language and format they understand, at least 30 days prior to a transfer or discharge. The policy also revealed the following Policy Interpretation and Implementation:
1b. Discharge refers to the movement of a resident from a bed in one certified facility to a bed in another certified facility.
2. Residents are permitted to stay in the facility and an not be transferred or discharged unless: a) the transfer is necessary for the resident's welfare and the resident's needs cannot be met in the facility.
3. Except as specified below, the resident and his representative are given 30-day advanced written notice on an impending transfer or discharge form this facility.
4. Under the following circumstances, the notice is given as soon as it is practicable but before transfer or discharge:
4a. The safety of individuals in the facility would be endangered.
4b. The health of individuals in the facility would be endangered.
4d. An immediate transfer of discharge is required by the residents' urgent medical needs; and/or
4e. The resident has not resided in the facility for thirty (30) days.
5. The residents and representatives are notified in writing of the following information:
5a. The specific reason for the transfer or discharge.
5b. The effective date of the transfer or discharge.
5c. The location of which the resident is being transferred or discharged .
5d. The location to which the resident is being transferred or discharged .
5e. An explanation of the residents' right to appeal the transfer or discharge.
6. A copy of the notice is sent to the Office of State Long -Term Ombudsman at the same time the transfer or discharge is provided to the residents and representative.
7. Residents have the right to appeal a facility-initiated transfer or discharge through the state agency that handles appeals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews, the facility failed to ensure the comprehensive Minimum Data Set (MDS) Assessment was accurately coded for two residents (Resident #46 and Resident #38) of four residents sampled for accuracy of assessments.
Findings included:
Review of Resident #46's admission Record revealed Resident #46 was admitted to the facility on [DATE], and readmitted to the facility on [DATE], with diagnoses of adjustment disorder with depressed mood, generalized anxiety disorder, schizoaffective disorder, and major depressive disorder.
Review of Resident #46's Florida Preadmission Screening and Resident Review (PASRR) Level II Determination Summary Report dated 3/13/2019 revealed, Resident #46 meets the definition of Serious Mental Illness, appropriate for nursing facility placement, and does not require specialized services.
Review of Resident #46's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/10/2024 revealed under Section A - Identification Information, Resident #46 did not have a serious mental illness or related condition.
Review of Resident #38's admission Record revealed Resident #38 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses of major depressive disorder, generalized anxiety disorder, unspecified mental disorder due to known physiological conditions, unspecified psychosis not due to a substance or known physiological condition, and dementia.
Review of Resident #38's PASRR Level II Determination Summary Report dated 1/20/2022 revealed Resident #38 meets the definition of Serious Mental Illness, appropriate for nursing facility placement, and does not require specialized services.
Review of Resident #38's MDS with an ARD of 3/20/2024 revealed under Section A - Identification Information, Resident #38 did not have a serious mental illness or related condition.
During an interview on 12/19/2024 at 11:35 a.m., with Staff D, Registered Nurse (RN)/MDS Coordinator, Staff D, RN stated she was responsible for completing the MDS Assessments. Staff D, RN verified Resident #46 and #38's MDS Assessments were inaccurately coded under Section A for PASRR, as both residents meet requirements for having a Level II PASRR.
During an interview on 12/19/2024 at 2:18 p.m. with the Director of Nursing (DON), she stated the facility does not have a policy and procedure related MDS Assessment completion, the facility just follows the regulation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure seven Residents (#210, #54, #65, #83, #85, #212 and #8) utilizing bed rails consented prior to instillation of the bed rails. The facility failed to assess the resident's need for side rails and failed to ensure the safety of the side rails for one Resident, #210, and working order of the side rails for one Resident, #54, of 7 of 47 residents sampled.
Findings Included:
1. During an interview with the DON on 5/13/21 at 3:08 p.m. she confirmed the residents side rails are assessed for need by the nurse on admission and they discuss them in the morning report. The DON confirmed they do not have a document that they use to assess the rails of each resident and do not have a consent for the side rails. The DON stated they just discuss the need for residents to have side rails every morning and use a check list for each room. Question #43 on the check list reads, Falling stars: check stars on doors, wheelchair and bracelet, Check safety interventions such as alarms in place and functioning, bed in lowest position, mats at bedside, etc. The document does not ask about side rails. The DON stated that is part of the safety check and should be understood.
During an interview with Staff member P, MDS on 5/13/21 at 3:21 p.m. she stated, all beds have side rails and they are documented on the nursing assessment on admission or quarterly. Staff member P, confirmed they do not have a side rail assessment and code no side rails for MDS.
During an interview with Staff member J, RN she stated on 5/13/21 at 4:07 p.m. the residents or family, sign two consents, one for medications and one for flu/pneumonia. Staff member J, RN confirmed the facility does not have a consent for side rails and provided an admission packet that did not include side rails.
During an interview with the Maintenance Supervisor, on 5/13/21 at 3:50 p.m. he stated, he was not aware of any issues with side rails not working and confirmed the staff have a daily room check list that each person is responsible for and should be checking the side rails as part of the check list.
During an interview on 5/13/21 at 4:14 p.m. with the maintenance assistant, he stated he was unaware of any broken or non working side rails.
2. During observation of resident #54's bed rails, Staff member J, RN confirmed they were half rails on each side at the head of the bed.
During an interview with Staff member P, MDS on 5/13/21 at 4:38 p.m. she confirmed the facility did not have bed rail consents and did not have care plans related to bed rails.
3. Observation of Resident #210 on 5/12/21 at 11:28 a.m. revealed the resident lying in bed with 3 side rails. The left side of her bed was observed with one half rail. The right side of the bed was observed with two quarter rails. The resident was observed lying in the center of the bed with the head of the bed elevated slightly and her eyes closed.
Observation of Resident #210 lying in bed on 5/13/21 at 2:15 p.m. revealed the resident with one half rail. Two quarter rails on the right side of the bed. All three rails were raised. The resident was elevated slightly and lying in the center of the bed. She was watching television with the head of the bed elevated slightly.
Observation and interview on 5/13/21 at 3:40 p.m. with the resident and her daughter at her bedside. The daughter stated she did not consent to have the bed rails and neither did her mother but said her mother likes having side rails to assist her with turning. Resident #210 stated she like the side rails and the daughter confirmed she had not been injured with the side rails and was new to the building this week.
During medication administration on 5/14/21 at 9:45 a.m. the resident was observed sitting upright taking her medication. The two quarter rails on the right side were observed coming toward each other, overlapping one another.
Observation on 5/14/21 at 11:30 a.m. revealed the right side of the bed changed to 1/2 rails.
Resident #210 was admitted on [DATE] with diagnoses of fracture of left pubis, per the admission sheet.
Review of the nursing comprehensive evaluation dated 5/9/21 revealed in section 9) Siderails/enablers/restraints: checked as side rails are not in use at this time.
Review of physician order dated 5/14/21 for bilateral 1/2 side rails while up in bed as enabler.
During an interview on 5/13/21 at 4:10 p.m. the DON confirmed the three bed rails and observed the two right sided 1/4 rails come together and overlap in an unsafe manner.
4. Observation of Resident #54 on 5/11/21 at 12:30 p.m. the resident stated she did not feel good and had diarrhea. She was observed with half rails up on both sides of the bed.
During an interview on 5/13/21 at 3:00 p.m. Resident #54 stated her bed rail has been broken since she arrived. She stated she gets out of bed on her own by sliding around the side rail on the right side of the bed to transfer to her chair and confirmed it's difficult but she has told people and it's still not fixed. She stated the left side of her bed is the window and does not have enough room to scoot around with the wheelchair. The Resident was observed with 1/2 side rails on the top of the bed and the button on the right side of the rail was missing.
Staff member C, unit manager confirmed on 5/13/21 at 3:43 p.m. the right side bed rail did not go up or down and stated he was calling maintenance and had not been told about the rail.
Staff member I, CNA confirmed on 5/13/21 at 3:47 p.m. the side rail has been broken for a long time and stated she told the maintenance assistant but did not write it in the book. She stated to the resident Are you the one who had the emergency and we could not get the rail down and had to take the whole thing off? then said, oh no, that was some one else!
Review of the admission nursing comprehensive evaluation dated 3/19/21 revealed section 9. Siderails/enablers/restraints as side rails are not in use or required at this time.
Review of the minimum data set (MDS) dated [DATE] revealed a brief interview for mental status (BIMS) of 15, cognitively intact.
Review of physician orders dated 5/14/21 revealed the resident to have bilateral 1/2 rails up while in bed as enabler.
Resident #54 was readmitted on [DATE] for diagnoses related to end stage renal disease and paraplegia.
5. Observation of Resident #8's room revealed the resident with bilateral 1/2 side rails without padding on his bed on 5/12/21 at 11:40 a.m.
Review of the nursing comprehensive evaluation dated 8/27/20 revealed the resident with a quarterly evaluation. Section 8 for side rails, indicated the resident has side rails in use or are being considered for use. Section 01b) indicated reasons for side rail use was resident request for safety. Medical symptoms that contribute to the resident's need for side rails documented as balance problems. Section 01c) indicated siderails are recommended as an enabler to assist with bed mobility/transfers. Recommended type of rails are documented as 1/4 rails.
Review of the Minimum Data Set, dated [DATE] revealed a Brief interview for mental status as 14, cognitively intact.
Review of Section G) functional status dated 4/28/21 revealed in section B for transfer required extensive assistance with two plus persons physical assistance.
Review of physician orders reflected padded 1/2 side rails for seizure precautions every shift for prophylaxis dated 5/14/21.
Resident #8 readmitted on [DATE] for history of traumatic brain injury, injury of head, and convulsions.
6. Resident #65 was observed on 5/12/21 at 2:26 p.m. sitting up in bed with bilateral 1/2 bedrails up and padded.
Resident observed lying in bed on 5/13/21 4:50 p.m. with bilateral padded, 1/2 side rails up and confirmed by staff Member J, RN.
Review of current physician orders revealed:
Bilateral 1/4 padded side rails up while in bed for seizure precautions dated 1/20/21.
7. Observation of Resident #83 on 5/12/21 at 10:00 a.m. sitting on the side of the bed with bilateral 1/2 rails.
Observation of Resident #83's side rails on 5/13/21 at 4:10 p.m. confirmed by Staff member J, RN were 1/2 rails without padding.
Review of the care plan revealed on 4/13/21 a focus area of risk for injury/complications related to seizure disorder. Padded siderails as ordered.
Review of the admission nursing comprehensive assessment dated [DATE] revealed section 9. Siderails/enablers/restraints as side rails are in use or are being considered for use. Reason for side rail use is resident request for safety. Medical symptoms that contribute to the resident's need for side rails does not have seizure disorder checked. Side rail recommendations checked as siderails are recommended as an enabler to assist with bed mobility/ transfers. C. siderails are recommended for use to promote patient safety. 1/4 rail with alternatives to side rails discussed with resident and precautions.
Review of physician order revealed the resident to have padded 1/2 side rails for seizure precautions every shift for prophylaxis dated 5/14/21.
8. Observation of Resident #85 in bed on 5/13/21 at 4:00 p.m. lying in a low position with floor mats down and 1/4 rails up on the bed.
Review of the record showed no assessment provided or consent for enablers.
Resident admitted on [DATE] for diagnoses of encephalopathy and Alzheimer's.
Observation of 1/4 rails confirmed on 5/13/21 at 4:18 p.m. with Staff member J, RN.
9. Resident # 212 was admitted on [DATE] with diagnosis of pulmonary mycobacterial infection, and sepsis, per the admission record.
Review of the physician orders revealed bilateral 1/4 bed rails up as enablers dated 4/30/21.
Review of the admission nursing comprehensive evaluation dated 4/29/21 revealed Section 9 as siderails/enablers/restraints checked as side rails are in use or are being considered for use. Reasons for side rail use are resident request for safety, related to weakness. Side rail use is not indicated at this time. Siderails are recommended as an enabler to assist with bed mobility/transfers. Type of bed rails are 1/4 rails.
Observation was made of Resident #212 in bed on 5/12/21 with 1/4 rails up.
Observation of Resident #212's bed rails was confirmed as 1/4 rails by Staff member J, RN on 5/13/21 at 4:21 p.m.
10. During an interview with the DON on 5/14/21 at 10:45 a.m. she confirmed the facility stayed late last night to complete the bedrail audit and to obtain consents for bedrails and assessments. The DON confirmed the broken bed rail for Resident #54 was fixed or getting fixed and Resident #210's 1/4 rails were removed and a 1/2 rail put up for safety. The DON stated the rooms should be completed at 10:45 a.m. on 5/14/21. The DON stated they have completed 100 percent audits on all bedrails and confirmed they are in working order and safe for the residents.
11. Review of the facility policy for proper use of side rails dated 12/2016, two pages revealed: The purposes of these guidelines are to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms. 2. Side rails are only permissible if they are used to treat a resident's medical symptoms or to assist with mobility and transfer of residents. 3. An assessment will be made to determine the resident's symptoms, risk of entrapment and reason for using side rails. When used for mobility or transfer, an assessment will include a review of the resident's a. bed mobility, b. ability to change positions, transfer to and from bed or chair, and to stand and toilet. c. risk of entrapment from use of side rails. 4. The use of side rails as an assistive device will be addressed in the residents care plan. 5. Consent for using restrictive devices will be obtained from the resident of legal representative per facility protocol. 7. Documentation will indicate if less restrictive approaches are not successful, prior to considering the use of side rails. 9. Consent for side rail use will be obtained from the resident or legal representative, after presenting potential benefits and risks. 11. The resident will bed checked periodically for safety relative to side rail use. 15. Facility staff, in conjunction with the attending physician will assess and document the resident's risk for injury due to neurological disorders or other medical conditions.

Based on observations, record review and interview the facility failed to provide appropriate respiratory care for 4 of 47 (#13, #31, #93, #47) sampled residents
Findings included:
1. Review of Resident #13's record revealed that she has a current order for oxygen O2 via N/C (nasal cannula) at 3LPM (liters per minute) every shift for COPD (chronic obstructive pulmonary disease)
During the survey the following observations were made of #13's oxygen (O2) tubing:
-On 05/11/21 at 11:42 AM the O2 tubing was noted on the floor.
-On 05/12/21 at 8:40 AM the O2 tubing was noted on the floor.
-On 05/13/21 at 8:51 AM O2 tubing on floor.
(Photographic Evidence obtained)
2. Review of Resident #31's record revealed she has a current order for 2 lit O2 via N/C Continuous every shift for pinched esophagus.
During the survey the following observations were made of #31's oxygen tubing:
On 05/11/21 at 1:36 PM the O2 tubing was noted on the floor.
On 05/12/21 at 8:40 AM the O2 tubing was noted on the floor.
On 05/13/21 at 8:51 AM the O2 tubing was noted on the floor.
(Photographic Evidence Obtained)
3. Review of Resident #93's record revealed that she had a current order for Albuterol Sulfate Nebulization Sol (5 MG/ML) 0.5% 1 vial inhale orally via nebulizer three times a day for SOB and 1 vial inhale orally via nebulizer one time only for SB for 1 day.
During the survey the following observations were made of #93's Nebulizer tubing:
-On 05/11/21 at 11:27 AM the nebulizer tubing was noted to be exposed and hanging in garbage bin.
-On 05/12/21 at 8:40 AM the nebulizer tubing was noted to be exposed and hanging next to garbage bin.
-On 05/13/21 at 8:51 AM the nebulizer tubing was noted to be exposed and hanging next to garbage bin.
(Photographic Evidence Obtained)
4. An interview was conducted on 05/13/21 09:25 AM with staff Q, LPN East unit manager, who reported that the respiratory therapist comes in 1 time a week and changes the equipment and tubing and in between the facility has their own supplies to change all respiratory equipment as needed including tubing. He reported that tubing is dated with initials when changed. Observation of the tubing at this time with the LPN present revealed that the tubing was on the floor around the wheels of the over bed table for resident #31; tubing was hanging from the storage bag and resting on the side of garbage bin for Resident #93; and tubing was resting on the floor for Resident #13. The LPN reported that the tubing was not appropriately stored and should never be on the floor. He reported that the aides should report this to the nurse so that the tubing could be changed.
An interview was conducted on 05/13/21 at 09:35 AM with Staff R, Agency CNA who said that if the tubing is noted on the floor it should be thrown away right away and the nurse notified. It should never be on the floor.
An interview was conducted on 05/13/21 at 09:39 AM with Staff K , LPN who reported that all tubing should be properly stored. Staff should let nursing know that the tubing needs to be changed. She reported that her expectation is that tubing not be on the floor or resting in or on the garbage cans and if it is, it should be reported to nursing so that it can be changed.
During an interview on 05/13/21 at 09:48 AM with Staff S, LPN reported that all tubing should be dated and bagged and when not in use the tubing should be in the bag. He reported that the tubing should never be on the floor. If it is on the floor the tubing should be changed.
An interview on 05/13/21 at 09:48 AM with the DON revealed that oxygen tubing should be in a bag labeled and dated. The tubing should never be on the floor or in/on the garbage.
5. Resident #47's admission Record revealed an admission date of 12/12/2020 with diagnoses of paroxysmal atrial fibrillation (AFIB), and chronic obstructive pulmonary disease (COPD).
Resident #47's MDS [Minimum Data Set] Nursing Home Quarterly . revealed under Section C: Cognitive patterns revealed a Brief Interview for Mental Status Score of 8 with no behaviors of inattention, disorganized thinking, or altered level of consciousness. Section G: Functional Status revealed Resident #47 required extensive assistance with two-people to assist for bed mobility and transfer. Resident #47 required extensive assistance with one person to assist for personal hygiene and dressing. Section O: Special Treatments, Procedures, and Programs revealed Resident #47 received oxygen therapy as a respiratory treatment.
Resident #47's Order Summary Report revealed an active physician order, dated 02/12/2020, for O2 [oxygen] @ [at] 2L [liters] via nasal cannula continuous.
Resident #47's Care Plan revealed a focus area, initiated on 12/12/2020, that [Resident #47] has a potential for complications of respiratory distress r/t dx [diagnosis] of: COPD. Interventions for this focus area included administering medications as ordered, administering O2 as ordered, and performing lung sounds and respiratory assessments needed. Further review of the Care Plan revealed a focus area, initiated on 12/12/2020, that [Resident #47] has a self care deficit with dressing, grooming, bathing r/t [related to]: generalized weakness, AFIB, COPD- [Resident #47] tends to refuse to get out of bed. Interventions for this focus area included instructions to administer medication as ordered.
During an observation on 05/11/21 at 11:17 a.m. Resident #47's oxygen tank was turned on and operating at 4L. Resident #47 stated her oxygen is supposed to be operating at 4 L, and no staff member has touched or adjusted her oxygen level.
A follow-up observation on 05/12/21 at 2:15 p.m. revealed Resident #47's oxygen operating at 4 L. Resident #47 stated she did not touch or adjust the oxygen tank. Resident #47 stated no staff member has touched or adjusted her oxygen tank recently either. Photographic evidence was obtained of the oxygen tank.
An interview on 05/13/21 at 4:06 p.m. with Staff E, Licensed Practical Nurse (LPN) revealed Resident #47 is bed ridden. While the Resident does get out of bed from time to time, she prefers to stay in her bed. Staff E, LPN stated the oxygen tanks should be checked at least once daily for monitoring. Staff E, LPN stated if a resident is receiving oxygen levels much higher than the level ordered it can cause respiratory problems. Prior to administering oxygen at a higher level than ordered, the doctor should be called to verify it would be appropriate.
On 05/13/21 at 4:15 p.m., Staff E, LPN observed and verified Resident #47's oxygen tank was operating at 4L. Staff E stated he personally has not turned up the oxygen, and CNAs [certified nursing assistants] should not be turning up the oxygen . [Resident #47] is unable to turn it up because she is bed bound . Staff E, LPN stated he was unsure of how the Resident's oxygen tank was doubled from 2L to 4L in its administration.
An interview on 05/13/21 at 4:25 p.m. with the Director of Nursing (DON) revealed the expectation is for physician orders to be followed and that nursing staff are expected to check a resident's oxygen administration level once a day to verify it is operating properly.
A policy review of Medication and Treatment Orders, revised July 2016, revealed . Orders for medications and treatments will be consistent with principles of safe and effective order writing . Medications shall be administered only upon the written order of a person fully licensed and authorized to prescribe such medications in this state .

Based on observations, interview and record review the facility failed to provide activities of daily living (ADL's) for 2 of 47 (#57, #74) sampled residents related to nail care for Resident #57 and bathing for Resident #74.
Findings included:
1. Observations on 5/11/21 at 12:20 PM of Resident #57 found the resident lying in bed with his his right hand under the sheets and his left hand exposed. It was noted that his finger nails on his left hand were elongated about half an inch from the top of his fingers. Interview with the resident at this time revealed that the resident did not like his nails long. During this interview the resident reported that his right hand is contracted and the nails dig into his hand and it hurts. Observation of the resident's right hand revealed that his right hand was contracted in the closed position, exposing only his thumb nail and first finger nail. The first fingernail was noted to be elongated a half an inch from the top of the finger, pointed in shape and jagged edges with a brown substance under the nail. The resident's thumb was noted to shaped in a point with jagged edges.
Resident # 57's care plan included a focus area of potential for complications r/t contractures of: (R) elbow, (R) wrist, (R) shoulder, (R) fingers (Initiated 9/9/2020).
Observations of Resident #57 on 5/12/21 at 8:50 AM revealed that the resident was lying in bed. It was noted that the resident's nails had still not been groomed. Interview with the resident at this time revealed that the staff had not yet cut his nails.
Observations of Resident #57 on 5/13/21 at 8:58 AM revealed the resident lying in bed. It was noted that the residents fingernails were still long and in need of grooming. While Interviewing the resident at this time, Resident #57 reported that he would like his nails cut.
Observations of Resident #57 on 5/14/21 at 7:40 AM found the resident lying in bed still noted with long fingernails. Observations of the residents left hand was noted with all 5 fingers with elongated fingernails that were about half an inch above the top of the finger. Observations of the resident's right hand was noted to be contracted in the closed position with the 2 fingernails exposed and noted to still have a black substance under the first finger nail. Interview with the resident at this time revealed that no one had cut his nails and that he would like them cut and that the nails on his right hand was continuing to dig into his hand because the nails were too long.
Interview on 5/14/21 at 7:45 AM Staff O, Registered Nurse (RN), revealed that the Certified Nursing Assistants (CNA) need to be completing the residents ADL's and that they should be asking the resident each time they provide care if they would like their nails trimmed.
Interview on 5/14/21 at 7:50 AM with Staff C, RN [NAME] unit manager, reported that the resident always refused to get his nails cut.
Interview on 5/14/21 at 8:07 AM with Staff A, Occupational Therapy (OT) reported that the resident had a contracture to his right hand and would often refuse care to the hand. She reported that, at times, the resident would allow for his hand to be soaked to allow for cleaning. She reported that the resident, at times, would refuse care to this hand.
On 5/14/21 at 8:13 AM, during an observation of the resident with the OT and the Director of Rehab (DOR) present, found the nurse and the aide were in the resident's room providing nail care at this time. It was noted that all nails on his left hand were trimmed and filed and the two exposed fingernails on his right hand were pointed and jagged with a black substance under the nail. The resident would not allow the OT to open his palm as he reported that it hurt.
Interview on 5/14/21 at 8:50 AM with the Director of Nursing (DON) revealed that her expectation was that staff provide ADL care including cutting of nails. She reported that, if needed, this task can be done by nursing. She reported that she was aware that this resident had a contracture, but, has the expectation that every time the staff go into the room, they should look at the resident's nails and offer nail care, if needed, and if the resident refuses, they should let the nurse know.
On 5/14/21 at 1:09 PM The DON provided a grooming log, dated 4/21/21, and reported that this document was used for audits. She reported that this audit was done on 4/21/21 and that the resident refused nail care. The DON reported that the resident had been offered nail care since this date but that it was not documented.
Review of the facility's Policy titled, Activities of Daily Living (ADLs), Supporting with a revision date of March 2018 revealed that Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.
Review of the facility policy titled Fingernails/Toenails, Care of with a revised date of February 2018 revealed under the sub-heading of General Guidelines
1. Nail care includes daily cleaning and regular trimming.
Under the sub-heading of Documentation,
'The following information should be recorded in the resident's medical record:
1. The date and time that nail care was given.
5. Any problems or complaints made by the resident with his/her hands or feet or any complaints related to the procedure.
6. If the resident refused the treatment, the reason(s) why and the intervention taken.
2) During an interview on 05/11/21 at 10:10 a.m., Resident #74 stated she has been in the facility for about a month and had only received one shower. Resident #74 stated she was asked a while ago if she wanted one, but, Resident #74 said, no not right now and since then another shower had not been offered to her. Resident #74 said, I would like a shower and I think I'm supposed to be getting one at least once a week. Resident #74 stated she spoke to a facility worker on 5/10/21 and was told she would get a shower.
A follow-up interview on 05/12/21 at 03:25 p.m. with Resident #74 revealed, . showered last night but it has been a while and I think I will be getting one at least once a week now.
Resident #74's admission Record revealed an admission date of 04/01/21 with medical diagnoses of chronic kidney disease (CKD), unspecified kidney failure and acidosis.
Resident #74's MDS [Minimum Data Set] 3.0 Nursing Home Comprehensive ., dated 4/7/21, revealed under Section C: Cognitive Patterns a Brief Interview for Mental Status score of 15, which indicated no cognitive impairment or behaviors of inattention, disorganized thinking, or altered level of consciousness.
The MDS 3.0 Nursing Home Comprehensive (4/7/2021) ., Section G: Functional Status revealed Resident #74 required extensive assistance with one person to physical assist for dressing and personal hygiene. Resident #74 was total dependence on staff for bathing. Section F: Preferences for Customary Routine and Activities revealed it was Very Important for Resident #74 to . choose between a tub bath, shower, bed bath, or sponge bath .
Resident #74's Care Plan revealed a focus area of . self care deficit with dressing, grooming, bathing r/t [related to]: generalized weakness, Anemia, CKD ., initiated on 04/02/21. Intervention for this focus area included providing hands on assistance with dressing, grooming, and bathing as needed, and staff to anticipate resident's needs with activities of daily living. The Care Plan revealed another focus area of . has a strength in communication . is able to hear at normal tones, speech is clear and easily understood. Communicates needs to staff, initiated on 04/02/21.
Resident #74's Task revealed Task Description . Prefers showers: refer to shower sheet for day and shift.
A review of Resident #74 unit's shower schedule sheet revealed DO NOT CHANGE WITHOUT UNIT MANAGER'S APPROVAL!!! [Resident #74's Unit] SHOWERS 3-11PM . Resident #74's room number was listed under the Tuesday and Friday shower day rotation.
In an interview on 05/13/21 at 11:57 a.m. Staff N, CNA, stated the procedure for showering and bathing is to document on the shower sheets which included the residents' skin condition and the type of bath that was provided. Staff N, CNA said . for instance if they [residents] are given a bed bath, then the CNA must sign the document and file it into the shower book. Staff N, CNA stated if a resident refuses a shower, then they must go back . a few times to see if they want it at a different time or try to talk with them about what may be going on that they do not want it. If the resident continues to refuse, they must go to the nurse, report it, and then the nurse must go speak to the resident. If the resident still refuses, then they must document onto the shower sheet that they refused. Staff N, CNA, stated Staff C, RN/Unit Manager, was responsible for filing the shower sheets from previous months.
In an interview on 05/13/21 at 12:08 p.m. with Staff C, RN revealed the shower sheets are filed away at the end of the month. Residents on the new admission unit are still provided with showers if their medical diagnosis allows for it. Staff C, RN, stated, if a resident refuses or requests a shower at another time, then the resident would be accommodated according to their preferences.
An interview on 05/13/21 at 12:55 p.m. with the DON revealed the facility has a shower schedule for residents, depending on their room number. The CNAs complete the shower sheets and provide it to the nurse on duty who signs it prior to filing it into the binder. If a resident refuses, the refusal is written on the shower sheet and the nurse is notified. The staff will go back to the resident a couple more times. If the resident continues to refuse then, we talk to them [the resident] about a different shift or time, and then reproach the next time and if they still refuse then the family is called . it is the aides' responsibility to ask if the resident wants a shower . The CNAs will also document in the online medical system under the showering task that a shower or bath was provided.
During the interview on 05/13/21 at 12:55 p.m. Resident #74's online medical record POC [Point of Care] Response History was reviewed with the DON and it was revealed Resident #74 had one documented shower on 4/22/21. Per the online POC Response History Resident #74 did not receive another shower until 5/11/21.
A follow-up interview on 05/13/21 at 2:25 p.m. with the DON revealed both facility wing shower binders were reviewed and no completed shower sheets for Resident #74 were found.
A review of Resident #74's Progress Notes, dated 4/2/21 to 5/13/21, revealed no notations related to shower refusals.
3. During an interview on 05/14/21 at 12:07 p.m. Resident #74's Healthcare Surrogate revealed she speaks with Resident #74 daily and Resident #74 stated she was not getting a shower. The Healthcare Surrogate stated she filed a grievance about a month ago regarding Resident #74 not getting a shower before she was provided with one. The Healthcare Surrogate stated she spoke to a facility worker recently, again, regarding the lack of provided showers and Resident #74 informed her that she was provided with a shower on 5/11/21. The Healthcare Surrogate said . [Resident #74's] body may be going but her mind is right. The Healthcare Surrogate stated Resident #74 is very consistent in telling her that she had not be given a shower, and Resident #74 . even called her the other day . and let her know that she had finally received one.
A policy review of Bath, Shower/Tub, revised February 2018, revealed . The purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin . Documentation 1. The date and time the shower tub bath was performed. 2. The name and title of the individual(s) who assisted the resident with the shower/tub bath. 3. All assessment data . obtained during the shower/tub bath. 4. How the resident tolerated the shower/tub bath. 5. If the resident refused the shower/tub bath, the reason(s) why and the intervention taken. 6. The signature and title of the person recording the data. Reporting 1. Notify the supervisor if the resident refuses the shower/tub bath. 2. Notify the physician of any skin areas that may need to be treated. 3. Report other information in accordance with facility policy and profession standards of practice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility did not ensure a home like environment related to ensuring resident rooms, and handrails, used by residents for ambulation, were kept in good repair on two of two wings (East and West) for Rooms #9, #44 and # 50.
Findings included:
During a facility walk through, observations on 05/11/21 beginning at 9:30 a.m. revealed the ceiling in disrepair above the window bed inside room [ROOM NUMBER]. The ceiling was chipped, peeling, and hanging revealing the insulation foam. Photographic evidence obtained.
An observation inside room [ROOM NUMBER] on 5/11/21 at 10:45 a.m. revealed a large hole at the base of the wall on the right side of the entrance door upon entering the room. Further observation of the room revealed the wall above the window bed to be in disrepair. The wall had a large hole with insulation foam exposed. The flooring by the window bed at the base of the wall, underneath the resident's bed, was in disrepair related to the lining peeling off. The window bed headboard was in disrepair with the wood peeling and sticking into the air. Photographic evidence was obtained of the above-described disrepair.
An observation inside room [ROOM NUMBER] on 05/11/21 at 2:14 p.m. revealed a large hole at the base of the wall upon entering on the right side. The resident residing in the door side bed stated the hole has been present since moving into the room. Photographic evidence obtained.
During a facility walk through, observations on 05/13/21 beginning at 10:00a.m. revealed the handrail located on the East wing between rooms 16-18 was in disrepair. The handrail was disconnecting from the wall and loose. The nails connecting the handrail to the wall were exposed. The handrail located on the [NAME] wing between rooms 56-62 revealed the handrail was loose and disconnecting from the wall. The nails connecting the handrail to the wall were exposed. Photographic evidence obtained. An additional observation inside room [ROOM NUMBER] upon entering revealed at the base of the wall on the right side a hole with the [NAME] around the hole soft to the touch and caving in.
During an interview on 05/13/21 at 3:35 p.m. the Maintenance Director stated the facility has a process in which each morning, and at minimum of three times a week, facility walk throughs are completed with a checklist. Part of the facility walk through each unit includes checking inside the resident rooms for any concerns such as cleanliness and disrepair. The facility takes a proactive approach and if any safety concerns are identified it is immediately reported and repaired.
An interview on 05/13/21 at 3:44 p.m. inside of the Nursing Home Administrator's (NHA) office with the NHA, Director of Nursing (DON) and the Regional Nurse Consultant revealed room check lists are completed daily throughout the building. A set of rooms are assigned to an individual who must complete observations and interviews with residents for concerns. If there are any issues inside of the room that need to be addressed, then it is reported. The NHA and the Regional Nurse Consultant confirmed this is done to identify any concerns in the rooms and units for safety and room conditions.
On 05/14/21 at 10:00 a.m., a facility walk-through was completed with the Maintenance Director. The Maintenance Director confirmed that part of the daily rounds included checking the handrails and the resident rooms for any repairs or other safety concerns. He stated, if any concerns or issues are identified, they are logged into the maintenance logbook as well as discussed during the morning meetings. He stated that if the issue is not logged into the maintenance logbook, he would not be aware of it for repair. The Maintenance Director confirmed the wall, ceiling, and flooring disrepairs inside the above-mentioned rooms. Upon observation of the handrails loose and in disrepair, the Maintenance Director confirmed it would be considered a safety risk and should be reported in the maintenance log books within a few days of the observation. The East wing and [NAME] wing maintenance logbooks were reviewed from April 2021 to May 2021 and the Maintenance Director confirmed no notations related to room or handrail disrepairs.
A review of Daily QAPI [Quality Assurance Performance Improvement] Rounds, revised 4/8/21, revealed . East/West Wings-Monitor halls specifically for patient concerns and assist with care issues. Check remains, and any devices. Check call bells for placement and water cups, privacy curtains, w/c [wheelchair] cleanliness, linen in appropriate places, etc. Help to ensure Dining rooms on East and [NAME] are clean . DEPARTMENT HEADS/MANAGERS ASSIGNED ROOMS FOR DAILY RESPONSIBILITIES Must be done prior to daily QAPI Meeting!!! .
During an interview on 05/13/2021 at 3:48 p.m., the Maintenance Director stated the Quality Assurance Check List for Compliance Rounds Monitoring, revised 5/23/27, did not specify handrail conditions but it would fall under number 43.
A review of Quality Assurance Check List for Compliance Rounds Monitoring, revised 5/23/17, revealed . 16. Is furniture clean and dust free including chairs, lamps, tables/dressers and bed frames? Are light fixtures dust-free? Are outside room plates dust free . 21. Are floors under beds and moveable furniture clean and free of dust? . 40. Housekeeping: Check vents in nutrition room, soiled utility, offices, resident's bathrooms, dietary, therapy, activity room . 23. FALLING STARS: . Check safety interventions such as alarms in place and functioning . REMIND resident of safety interventions .
A policy review of Maintenance Service, revised December 2009, revealed . Maintenance service shall be provided to all areas of the building, grounds, and equipment . The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times . Functions of maintenance personnel include, but are not limited to: . b. Maintaining the building in good repair and free of hazards . J. providing routinely scheduled maintenance service to all areas . 3. The Maintenance Director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner

Based on observation, interview, and policy review the facility failed to ensure kitchen food-contact equipment and serving utensils were stored clean and free of grime and debris. The food contact equipment and utensils are provided to residents residing on two of two facility wings. (East and West)
Findings included:
During the comprehensive kitchen tour on 05/14/21 at 10:31 a.m., The Kitchen Manager stated the process when equipment comes into the kitchen for cleaning is to pre-rinse it and then run the equipment through the dishwasher for sanitization, prior to storing it, as clean on the drying racks. Staff L, Kitchen Aide was observed in the process of using the dish washer. Three storage racks were observed on the clean side of the dish washer stocked with bowls, serving trays, and bowl lids. Staff L, Kitchen Aide stated the three racks were used as drying racks and equipment is stored there coming from the dishwasher as clean.
An observation of the equipment on the clean drying racks, during the observation and interview on 05/14/21 at 10:31 a.m., revealed ten serving trays with unclean with food debris, three bowls unclean with food debris, and two lids unclean with food debris. The Kitchen Manager confirmed the items were unclean and instructed Staff L, Kitchen Aide to to remove the items and re-clean them.
An observation on 05/14/21 at 10:37 a.m. revealed a storage rack next to the walk-in cooler. The Kitchen Manager confirmed the storage rack was a dry, clean, food equipment storage rack. Random selection of the food pots revealed two pots with food debris. The Kitchen Manager confirmed the food debris and removed the pots from the location for re-cleaning.
During an observation on 05/14/21 at 10:43 a.m. revealed a countertop stand mixer and a deli slicer. The stand mixer and the deli slicer were covered with a plastic bag over them. The Kitchen Manager stated the items were stored clean and are only placed under the plastic wrap post-cleaning. The Kitchen Manager stated the deli slicer was not used the day of 05/14/21. The plastic wrap was removed from the deli slicer and yellow food debris was observed on the back of the blade. The plastic wrap was then removed from the counter-top stand mixer, food grime and debris were observed on the underside of the stand mix by the metal connector. The Kitchen Manager stated the process is to clean the stand mixer prior to clean storage. The Kitchen Manager stated the expectation would be for the underside of the stand mixer at the mix connect to be clean. The Kitchen Manager stated both items would be re-cleaned.
On 05/14/21 at 11:15 a.m. Staff M, Kitchen Aide was observed placing knives, forks, and spoons into a utensil storage container by the steam table prep line. Staff M, Kitchen Aide stated the utensils were going to be used for the lunch food service line, which would be served to residents. An observation of the knives, forks, and spoons revealed old food debris. The Kitchen Manager confirmed the old food debris on the utensils and Staff M, Kitchen Aide began removing the items for re-cleaning. The Kitchen Manager stated kitchen staff were taught on how to visually inspect equipment prior to storing it as clean or using it to serve residents.
An educational review of Record of In-Service, dated 03/22/21, revealed . Staff to understand the proper procedure for cleaning/sanitizing equipment inspection and use of cleaning list . 1) All equipment must be cleaned & [and] sanitized before & after each use . 3. Equipment, plates, silverware and pans should be visually inspected prior to use for cleanliness . This educational in-servicing was signed by both Staff L, Kitchen Aide and Staff M, Kitchen Aide.
A policy review of Ware washing, dated October 2019, revealed . It is the center policy that all dishware and service ware will be cleaned and sanitized after each use 1. The Dining Services Director insures that the nutrition service staff is knowledgeable in proper technique for processing dirty dish ware to clean through the dish machine and proper handling of sanitized dish ware. 2. The Dining Services Director ensures that all dishware is air dried and properly stored .

Based on the sense of smell, interview and record review, the facility failed to maintain an environment free from odor on 1 of 2 (East wing) living units.
Findings included
Upon entry onto the East wing living unit on 05/11/21 at 11:01 AM strong odor of sewer smell was noted in hallway. Interview with Resident #55, who was sitting in the hallway at the time, revealed that the facility has an odor all the time and that she did not know what it is but that it smells very bad. Resident # 55 has a Brief Mental Status (BIMS) score of 15 (Cognitively intact), dated 3/18/21.
In an interview on 05/11/21 at 11:20 AM with the Administrator (NHA) revealed that the strong odor is coming from the grease trap and has been present in the facility for 1 week. He reported that a vendor came out and addressed the issue and placed some scents to help with the odor.
In an interview on 05/11/21 at 11:25 AM with the Maintenance Director revealed that the the odor in the facility is coming from the grease trap. He reported that a vendor came and cleaned it out 1 month ago, and that the smell came back about 3 weeks ago and a call was made to the vendor as well as the plumber 2 weeks ago. The Maintenance director was not able to verbalize any plan to resolve the odor. He reported that he had documentation of the contacts that he made on his facility issued phone and would attempt to screen shot and print the info.
On 05/11/21 at 12:01 PM the Maintenance Director provided a copy of an email, dated 5/11/2021 at 11:49 AM, indicating that As of two and a half weeks ago we received a call from Maintenance Director about sewer gas smell. We will be going out to the facility responding to the request on Tuesday May 18.
On 05/12/21 at 08:35 AM it was noted that the foul odor was still present on the East wing. Interview with Resident #103 at this time , who was wheeling himself down the hallway revealed that the smell is not good. Review of Resident #103's record, revealed a BIMS score of 10 (Moderate impairment) dated 4/26/21.
In an interview on 05/14/21 at 10:29 AM with the NHA revealed that the vendor was called and that they came in to change the grease trap related to the odor. He reported that he will provide the invoice.
In an interview on 05/14/21 at 10:43 AM the Maintenance Director provided an invoice from from a vendor, dated 3/25/21, that he says is for cleaning the grease trap. Information on the document was not clear and faded. He reported that this vendor visit has nothing to do with the current odor.
During an interview on 05/14/21 at 10:46 AM with the Maintenance Director and the NHA, the NHA reported that the 3/25/21 invoice is a result of the the facility calling the company to come in and address the odor, and they came in and cleaned out the grease trap. He reported that this solved the problem for a little while then the odor came back about 2 weeks ago. and that the vendor will be back in on 5/18/21.
On 05/14/21 at 11:00 AM a phone interview with Staff T vendor representative revealed that the facility had a service call on 3/25/21 which is part of their routine service as the facility is visited on a 60 day basis to clean their grease trap to comply with the city regulation. She reported that this visit was a routine visit and was not an emergency visit or to address odor. She reported that there had been no emergency visits to this facility
Review of the facility policy titled Quality of Care-Homelike Environment with a revised date of May 2017 revealed that 2. The facility staff and management shall maximize, to extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include:
f. Pleasant, neutral scents;
3. The facility staff and management shall minimize, to extent possible, the characteristics of the facility that reflect a depersonalized, institutional setting. These characteristics include:
b. Institutional odors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow their policy to appropriately store medications in one of five medication carts (East Wing); failed to lock one of five medication carts located in a high traffic area (Dementia Unit) and did not ensure medications were stored to prevent excess temperatures in One (West Wing Medication Room) of two medication rooms sampled.
Findings included:
1. On 05/13/21 at 08:46 p.m., an observation of Combigan 0.2-0.5 Oph Solution was on top of medication cart 1 on the East Wing. Staff K (LPN) was observed to be in room [ROOM NUMBER]D administering medication to a resident. The medication cart was also unlocked, in the dementia unit, a high traffic area with several residents passing by in wheelchairs and walking past the unlocked medication cart. No staff were observed to be near the medication cart. Staff K (LPN) was immediately interviewed once she left the room.
She indicated that she did not realize she left the medication out and did not lock the medication cart. (Photographic Evidence Obtained.)
2. On 05/13/2021 at 03:55 p.m., an observation of the Medication Cart One (1) on [NAME] Wing included a loose tablet in second drawer. Staff J Registered Nurse (RN) confirmed the presence of the unsecured white tablet. (Photographic Evidence Obtained).
3. On 04/13/2021 at 04:30 p.m., an observation of [NAME] Wing medication storage room was conducted with Staff C, Registered Nurse (RN), Unit Manager (UM). The room temperature was observed to be very hot. The cabinet that contains Over the Counter Medications (OTC) was opened; all 14 bottles were hot to touch each. Staff C (RN) UM touched several OTC bottles, and confirmed that they were very hot. An observation of five bottles of Medications was conducted of Acetaminophen, Anti-Diarrheal, B-Complex, Vitamin A, and Vitamin D3, all which had manufacturer instructions on the label of the bottle to store the medications at 20-25 degrees Celsius or 68-77 degrees Fahrenheit. (Photographic Evidence Obtained).
On 5/13/21 at 05:11 p.m., an interview with the Assistant Director of Nursing was conducted on the [NAME] Wing near the nurse's station where medication room was located. The ADON indicated she heard the conversation the surveyor had with Staff C, (UM) and stated ADON stated the maintenance man knows about the temperature, he was told last week.
An interview was conducted with the Director of Nursing (DON) on 05/13/2021 at
5:15 p.m. During the interview, the DON was informed of the observations made of the [NAME] Wing medication room being hot, the air not working inside the room, OTC medication bottles stored inside a cabinet being warm to touch. The DON stated, I will put a fan in the room. She was also informed that a unsecured, medication was found in the [NAME] Wing Medication Cart One (1)'s second draw. The DON indicated that the staff works hard on keeping the medication carts very clean, and that it's hard sometimes with the punch cards, as they can easily come out.
An observation was conducted on 5/14/2021 at 11:00 am, in the [NAME] Wing Medication Room, which had a fan in it, but not plugged in and turned on cooling the medication room. The maintenance Director indicated that he did not have a thermometer in the facility to check the temperature but had been using a thermometer that the kitchen uses to check the temperature of food. He brought one that was reading 73 Degrees Fahrenheit. He put it in the [NAME] Wing Medication Room and the thermometer temperature went up to 80 Degrees. The Maintenance Director revealed that the temperature of the room was hotter, and more humid the previous day. (05/13/2021)
Subsequent observations at 12:00 p.m. and 1:00 p.m. were conducted of the thermometer reading 80 degrees Fahrenheit. Staff C (UM) confirmed the temperature readings.
On 05/14/2021 at 01:02 p.m. an interview was conducted with the Maintenance Director. During the interview he stated, I was never told by anyone about the Medication Room, they told me it was the nurse's station on the [NAME] Wing, I had no idea, and if I did, I would have done something if I knew the medication room was hot.
An interview was conducted with the DON on 5/14/2021 at 02:00 p.m. During the interview, the DON was informed of the observations made in the [NAME] Wing medication room. She was also informed that the fan was not on in the room circulating the air, and that the five OTC medications were still in the cabinet. The DON was shown Photographic Evidence of the thermometer being utilized to measure ambient temperatures. The DON stated We will not use those (14) medications, we will discard every one of them and we will be getting a proper thermometer to check the ambient temperature.
4. On 5/14/2021 at 03:15 p.m., a telephone interview was conducted with the Pharm-D, Pharmacy Consultant. The Pharmacy Consultant was informed of observations made of Staff K (LPN) not locking her medication cart and of medication left out on top of the medication cart, while she was in a Resident room administering medication. The Pharmacy Consultant stated Medications should not be left out on medication carts, and they need to lock the medication carts when they are not around the medication cart. No loose medications should be left unsecure in med carts. Temperatures should be followed, manufacturer's recommendation for the gel tablets are there for a reason, and technically the five (5) Over the Counter (OTC) bottles should be discarded if the temperature was over 80 degrees. And technically, if it was hotter the previous day they all should be discarded, all 14 bottles, even the 9 bottles that should not be over 86 degrees.
5. A facility provided policy titled, Storage of Medications, with Revision Date November 2020, was reviewed and read under Policy Heading The Facility stores all drugs and biologicals in a safe secure and orderly manner.
Policy Interpretation and Implementation:
2. Drugs and biologicals are stored in the packaging containers or dispensing systems in which they are received.
6. Unlocked medication carts are not left unattended.