Indian Canyon Post Acute

Based on observation, interview, and record review, the facility failed to ensure controlled substances (a drug or medication whose use is strictly regulated by the government due to its high potential for abuse) were reconciled accurately and in accordance with facility's policy and procedure (P&P), when a licensed nurse signed the facility's narcotics reconciliation log prior to completing the required physical count of the controlled substances.This failure had the potential to result in inaccurate accountability of controlled medications, delayed identification of discrepancies, and risk for medication diversion (the unauthorized use of a medication by someone other than whom it was prescribed for).Findings:During an observation on December 3, 2025, at 7:12 AM, the narcotic reconciliation log titled, Controlled Drugs - Count Record (narcotic reconciliation log for the medication cart in the 400 hall), dated December 2025, the log was signed by the PM shift nurse (Licensed Vocational Nurse 1 [LVN 1]) for the 7am - 7pm shift but the AM shift nurse (LVN 2) had not yet signed the log and the physical count of the narcotics had not yet been performed by LVN 1 or LVN 2.During an interview on December 3, 2025, at 7:16 AM, with the Director of Nursing (DON), the DON stated nurses were supposed to sign the controlled drug reconciliation record after physically counting the controlled drugs and after verifying the count of the medications.During an interview on December 3, 2025, at 7:27 AM, with LVN 2, LVN 2 stated the normal process for reconciliation of controlled medications was that the AM and PM nurses (the nurse coming off shift and the nurse coming on shift) count the physical medications and then sign the reconciliation log after the count is verified. LVN 2 further stated the controlled substances log dated December 3, 2025, 7am-7pm shift was already signed by LVN 1 (PM nurse) but the physical counting of the medications had not yet been done. LVN 2 stated the counting of the controlled substances was supposed to be done concurrently (at the same time) with both the PM nurse (LVN 1), and AM nurse (LVN 2).During an interview on December 3, 2025, at 7:38 AM, with LVN 1, LVN 1 stated she signed the controlled substances reconciliation log titled, Controlled Drugs - Count Record, dated December 2025, for the med cart in the 400 hall, prior to performing the physical count of the controlled substances. LVN 1 further stated the facility policy was that the PM nurse and the AM nurse were supposed to count the controlled substances together first, then both nurses would sign the log. LVN 1 again acknowledged that she had signed the reconciliation log prior to physically counting the medications.During concurrent interview and record review on December 3, 2025, at 8:04 AM, with the DON, the facility's policy and procedure (P&P) titled, Narcotic Count, dated January 2025, was reviewed. The P&P indicated, It is the policy of this facility to justify amount of narcotics remaining when control of supply is released to nurse coming on duty.1. One RN [registered nurse] or one LVN/LPN [licensed vocational nurse/licensed practical nurse] going off duty and one RN or one LVN/LPN coming on duty must count and justify narcotics supply for each individual resident at the change of each shift. 2. After the supply is counted and justified, each nurse must record the date and his/her signature verifying that the count is correct. The DON stated the policy and procedure was not followed by staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to provide evidence it received, documented, and acted upon pharmacist recommendations of monthly medication regimen reviews (a pharmacist evaluation of a patient's entire medication regimen with recommendations in order to identify potential problems with ineffective drugs, harmful interactions, incorrect dosages etc.) for one of five residents (Resident 8) reviewed for unnecessary medications.This failure resulted in Resident 8 to be at increased risk for irregularities in the resident's medication regimen to go unidentified and uncorrected which could result in adverse drug effects and avoidable negative outcomes for the resident.Findings:During a review of Resident 8's admission Record (contains medical and demographic information), the admission Record, indicated Resident 8 was initially admitted to the facility on [DATE], with diagnoses which included hypertensive heart disease (heart problems that occur because of high blood pressure present over a long period of time), major depressive disorder (a serious mood disorder causing persistent sadness, loss of interest, and significant impact on daily life), anxiety disorder (a condition characterized by excessive fear or apprehension), and schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions).During a review of the facility document titled, Current Resident Listing for [name of the facility] with Medication Regimen Review activity between 9/1/25 and 9/27/25, (a document which indicates which residents' medication regimens were reviewed by the consultant pharmacist for the month of November) dated November 27, 2025, the document included the name of Resident 8 indicating the pharmacist did perform a review of Resident 8's medications for September 2025.During a review of the facility document titled, Consultant Pharmacist's Medication Regimen Review: Listing of Residents Reviewed with No Recommendations, dated September 1, 2025, through September 27, 2025, the document did not include the name of Resident 8 which meant the pharmacist had recommendations regarding Resident 8s medication regimen for September 2025.During a review of the facility document titled, Current Resident Listing for Indiana [Indian] Canyon Post Acute with Medication Regimen Review activity between 8/1/25 and 8/27/25, dated August 27, 2025, the document included the name of Resident 8 indicating the pharmacist did perform a review of Resident 8's medications for August 2025.During a review of the facility document titled, Consultant Pharmacist's Medication Regimen Review: Listing of Residents Reviewed with No Recommendations, dated August 1, 2025, through August 27, 2025, the document did not include the name of Resident 8 which meant the pharmacist had recommendations regarding Resident 8s medication regimen.During a review of Resident 8's electronic medical record, the pharmacist's recommendations regarding Resident 8's monthly medication regimen review for September 2025 and August 2025, was not found.During an interview on December 4, 2025, at 1:30 PM, with the Director of Nursing (DON), Resident 8's consultant pharmacist medication regimen review recommendations for September and August of 2025, were requested. The DON stated she was unable to find evidence of the pharmacist's recommendations for Resident 8's medication regimen review for September and August of 2025. The DON further stated she usually printed the pharmacist recommendations and provided them to the medical records department for follow up but states they were unable to find the recommendations. The DON further stated the consultant pharmacist would have sent her recommendations for Resident 8 for September and August of 2025 since the resident was not on the no recommendations lists for those months.During a review of the facility's policy and procedure (P&P) titled, Medication Regimen Review (MRR), dated January 25, 2025, the P&P indicated, 1. The drug regimen of each resident, which includes a review of the resident's medical chart; will be reviewed at least once a month by a licensed pharmacist; 2. Irregularities will be documented on a separate written report; that is sent to the attending physician, the facility's medical director and the director of nursing services and lists the resident's name, the relevant drug, and the irregularity the pharmacist identified. These reports will be acted upon. Procedure: 1. The pharmacist reviews each resident's medication regimen at least once a month in order to identify irregularities and to identify clinically significant risks and/or adverse consequences resulting from or associated with medications.

Based on interview, and record review, the facility failed to act promptly upon the resident council's grievances and recommendations when the Grievance Official (GO) failed to address or provide a rationale for the inability to act on the resident council's grievances and recommendations over a three-month period (August 2025 to October 2025) for 16 sampled residents (Residents 1 to 16). This failure had the potential to cause an undermining of residents' independence, a hindering of effective problem resolution and quality improvement, and ultimately creating an atmosphere of fear and distrust within the facility.Findings:During the entrance conference with the Interim Director of Nursing (IDON) on December 1, 2025, at 9:30 AM, the IDON stated Resident 41 was the resident council president.During an interview with Resident 41 and the Administrator (Admin) on December 1, 2025, at 3:17 PM, Resident 41 stated he was no longer the president of the resident council because he felt it was a waste of time since the facility never addressed the concerns raised by the council. The Admin stated the resident council president was Resident 19.During an interview with Resident 19 on December 1, 2025, at 3:28 PM, Resident 19 confirmed he was the resident council president and the group met about once per month. Resident 19 granted permission for a review of the resident council's meeting minutes over a three-month period.A review of the resident council meeting minutes dated August 2025, September 2025, and October 2025, was conducted. The following is a summary of the documented grievances and recommendations:Physical Therapy (PT): PT not doing enough, More PT not just once per week, resident not getting walks, PT for all body parts, an open gym for exercise.Nursing: Coming in turning call light off and walk back out again, staff complaining about getting things from the kitchen, not cleaning well after toilet use, sugar drop in independent residents and no one checks. Medications on time and correct medications, listen and respond to resident concerns, night shift nurses sleeping on the job and not providing showers.Dietary: More options for meal substitutions, more variety for daily meals, more variety for nighttime snacks, hot cereal not made correctly.Housekeeping: Clean the rooms better. Only cleaning bathroom not room itself, more clothes for men, more linen. Laundry to return correct clothes to the correct residents.Administration: listen and be more responsive. Operations Manager (OM) to attend meetings to understand residents' concerns. A resident council meeting was conducted on December 2, 2025, from 10 AM to 10:45 AM, 16 residents attended the meeting including the former president, Resident 41, and the current president, Resident 19. A summary of the documented grievances and recommendations from the resident council meetings held in August 2025, September 2025, and October 2025, was reviewed with the attendees. The attendees were asked whether the facility had addressed or responded to the council's grievances and recommendations for this three-month period. Approximately 50 percent of the attendees, including Residents 41 and 19, indicated that the facility had neither responded to nor addressed the council's grievances and recommendations during this three-month period.During an interview with the Admin on December 3, 2025, at 7:42 AM, the Admin stated the Grievance Official (GO) was the Social Services Director (SSD). The Admin stated the GO acted upon the resident council's grievances and recommendations.During an interview with the GO and the Activities Director (AD) on December 4, 2025, from 7:18 AM to 7:37 AM, The GO confirmed her role and responsibilities and stated that it was her responsibility to address grievances and recommendations from resident council meetings. However, the GO stated that the activities director had not provided her with minutes from these meetings for approximately six months, preventing her from addressing any issues or suggestions raised by the residents. The Activities Director (AD) stated she assumed her position in July 2025. The AD stated that no orientation or training was provided for the AD role, and she was unaware of the requirement to forward the resident council meeting minutes to the GO for action. The AD stated she handwrote the minutes for the resident council meetings and acknowledged the grievances and recommendations raised. The AD verbally communicated these issues to the Operations Manager (OM), the IDON, and the Dietary Services Supervisor (DSS), but noted that since it was not documented in writing, those individuals likely forgot. The GO stated that she could not adhere to the facility's policy and procedure titled Grievances, dated January 25, 2025, as she had not received the grievances and recommendations from the resident council meetings.During an interview with the OM and the Admin on December 4, 2025, at 8:04 AM, The OM and Admin stated it was the responsibility of the AD to provide the resident council meeting minutes to the GO, and it was the GO's responsibility to act upon the grievances and recommendations documented in the meeting minutes. The OM and Admin stated the facility had not acted promptly upon the resident council's grievances and recommendations. A review of the facility's policy and procedure (P&P) titled, Grievances, dated January 25, 2025, indicated, Policy: It is the policy of this facility to establish a grievance process to 1. Address resident concerns without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents; and other concerns regarding their facility stay; and 2. Make prompt efforts to resolve grievances the resident may have. Procedures: 1. The facility's grievance official is responsible for overseeing the grievance process, receiving and tracking grievances; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances; issuing written grievance decisions to the resident, if requested; and coordinating with state and federal agencies as necessary. 2. Resident and/or Resident Representatives have the right to file grievances orally or in writing, . 3. General concerns may be voiced at Resident Council meetings. 4. The Grievance Official evaluates and investigates the concern and takes immediate action to resolve the concern and prevent further potential violations of any resident's right while the alleged violation is being investigated. 6. The Grievance Official or designee responds to the individual expressing the concern within (3) three working days of the initial concern to acknowledge receipt and describe steps taken toward resolution.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive care plan to ensure Resident 89's optimal physical, mental, and psychosocial well-being when Resident 89 displayed a behavior of aggressively chewing on the thumb and first three fingers of the left hand, and the first two fingers of the right hand.This failure resulted in damage to the fingernails on Resident 89's left hand.Findings:A review of Resident 89's face sheet (a document that gives a summary of resident's information), undated, indicated an admission date of October 3, 2023. Resident 89 had diagnoses that included Alzheimer's disease (a progressive type of brain disease and is the most common cause of dementia) and dementia (an umbrella term for a collection of symptoms, such as memory loss, language problems, and impaired thinking skills, severe enough to interfere with daily life).During an observation and interview with Resident 89, Certified Nursing Assistants 2 and 3 (CNA 2 and 3) on December 1, 2025, from 4:05 PM to 4:35 PM, Resident 89 was in his room in bed and was wearing a short sleeve hospital gown with the blanket pulled up to his waist. The surveyor tried to engage Resident 89 in conversation, but Resident 89 made no eye contact nor spoke to the surveyor. Resident 89 was positioned in his bed, so he faced the wall to his right. Resident 89 was awake, staring at the wall and had his right two fore fingers in his mouth which he was aggressively chewing on and making vocalizations as he chewed. CNA 2 and CNA 3 stated the finger chewing had been an ongoing issue. They had attempted to give Resident 89 toys to hold and chew on, but Resident 89 would almost immediately drop the toy and forget about it. CNA 2 and CNA 3 explained that Resident 89 did not know to search for the toy once he had dropped it, so this approach had not been successful. CNA 2 stated he had asked the Licensed Vocational Nurse (LVN) charge nurse for mittens, but nothing came of it. CNA 3 assisted in visualizing Resident 89's fingers, it was observed that the fingernails on the left hand's thumb and first three fingers were severely affected. They were misshapen and deformed, exhibiting significant yellow discoloration, thickening, brittleness, and a crumbly texture. Furthermore, some of the affected fingernails had separated from the underlying nail bed. CNA 3 stated Resident 89 had chewed his left hand fingers a lot and had just started chewing on his right hand. Resident 89's right two fore fingers' nails and skin still looked healthy.During an observation and interview with the Interim Director of Nursing (IDON) on December 4, 2025, from 9:33 AM to 10:01 AM, the IDON stated she was not aware Resident 89's finger chewing had escalated to this point. The IDON stated there was no assessment on the fingernails on the Resident 89's left hand, This should have been picked up on the skin assessments and brought to the attention of the physician and then the wound nurse and it was not. The IDON stated when the CNAs did not get a response from the charge nurse they should have gone up the chain to the Registered Nurse (RN) supervisor and not waited this long to tell her on Monday December 1, 2025, that Resident 89 had a problem. The IDON stated there was no care plan to address this issue. After examining Resident 89's left hand fingernails, the IDON stated, This didn't happen overnight. The IDON stated Resident 89's finger-chewing behavior and nail deterioration should have been assessed and included in a care plan but were not.A review of the facility's policy and procedure (P&P) titled, Care Planning, dated January 25, 2025, indicated, Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation: 1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 7. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. 8. When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers. 9. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents ' conditions change. 10. The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition; b. when the desired outcome is not met; c. when the resident has been readmitted to the facility from a hospital stay; and d. at least quarterly, in conjunction with the required quarterly MDS [Minimum Data Set] assessment as needed.

Based on observation, interview, and record review, the facility failed to provide interpretive services to residents including Resident 45, whose primary language is other than English.This failure had the potential to compromise residents the ability to understand, comprehend, and effectively communicate their needs, rendering them unable to fully participate in their plan of care, likely leading to residents experiencing diminished self-esteem, social interaction withdrawal, and significant emotional distress.Findings:During an interview conducted on December 1, 2025, at 11:36 AM with Resident 45, it was revealed that Spanish is Resident 45's primary language, and he does not speak or understand English. Although he could respond to simple Yes/No questions spoken in English, he did so with visible hesitation and reservation. Resident 45 utilized his cell phone to contact his daughter, who subsequently assisted as a translator through the phone's speaker.Through his daughter's translation, Resident 45 communicated his frustration with being unable to convey his needs and preferences to the staff due to the language barrier. He expressed feeling more comfortable when Spanish-speaking staff members are available. However, he is not always assigned to Spanish-speaking staff due to staffing variances. This inconsistency in communication had contributed to his feelings of frustration and unease during his stay at the facility. Resident 45 indicated a strong preference for the facility to provide an interpreter to facilitate better communication and dialogue with staff members. He emphasized that having an interpreter would greatly enhance his overall experience through direct dialog with staff, ensuring that his needs and concerns are adequately addressed in a timely manner. A review of residents' 45 face sheet (a facility document that contains basic information about the resident) indicated he was admitted at the facility on January 7, 2025, with diagnoses which include hemiplegia with hemiparesis [weakness (hemiparesis) on one side of the body, ranging from mild to severe, often accompanied by complete paralysis (hemiplegia) on the same side, typically affecting the arm, leg, and sometimes face, due to brain injury disrupting nerve signals] following cerebral infarction affecting right dominant side, aphasia (disorder caused by brain damage that affects a person's ability to communicate by interfering with their speech), unspecified intracranial injury (damage to the brain or its surrounding structures inside the skull) without loss of consciousness, lack of coordination, type 2 diabetes, neuropathy (nerve damage or disease, often in the hands and feet, that causes symptoms like numbness, tingling, burning pain, or muscle weakness), chronic kidney disease stage 4 (kidneys have severe damage and function at only 15-29% of normal), hypertension (high blood pressure), and major depressive disorder(a mood disorder characterized by persistent feelings of sadness and a loss of interest in activities).A review of the Comprehensive Material Data Sheet (MDS - contains demographic information, resident assessment and care screening) dated September 26, 2025, identified Resident 45 ethnicity as Hispanic and noted that his preferred language is Spanish, requiring an interpreter for communication with medical or healthcare staff.A review of the Resident 45's Care Plan indicated, the resident has a communication problem related to a language barrier, impaired hearing, neurological symptoms, impaired cognition, depression, and aphasia. However, there are no interventions addressing the language barrier.During an interview with Licensed Vocational Nurse 4 (LVN 4) on December 1, 2025, at 3:22 PM, LVN 4 indicated that the facility does not provide interpretive services for residents who do not speak English. LVN 4 further stated that she utilizes the Google Translate App on her personal cell phone to communicate with these residents.During an interview with the Social Services Director (SSD) on December 1, 2025, at 3:49 PM, the SSD confirmed that the facility does not offer translation services for non-English speaking residents. The SSD further explained that she relies on staff members for translation when they are available and uses a translation application on her phone to communicate with residents when staff assistance is not accessible.During a concurrent record review and interview with the (SSD) on December 1, 2025, at 4:03 PM, the SSD confirmed that Resident 45 needs an interpreter to effectively communicated with staff. The Policy and Procedure (P&P) titled, Translation and/or Interpretation of Facility Services, undated, was reviewed with the SSD. The P&P states . 8. Competent oral translation of vital information that is not available in written translation, and non-vital information shall be provided in a timely manner and at no cost to the resident through the following means as available to the facility: . c. Contracted interpreter service; d. Voluntary community interpreters who are trained and competent in the skill of interpreting; and e. telephone interpretation service. The SSD acknowledged that the facility lacked interpreter services as of December 1, 2025, and agreed the facility's P&P was not followed. During an interview with the Operations Manager (OP) on December 3, 2025, at 8:58 AM, the OP acknowledged that the facility did not ensure non-English speaking residents could communicate effectively with staff through an interpreter as per the facility's policies and procedures.During an interview with the Director of Nursing (DON) on December 4, 2025, 11:33 AM, the DON acknowledged that non-English speaking residents were unable to effectively communicate with staff and participate in their plan of care due to facility's failure to provide interpreter services as specified in facility's policy and procedure. The DON recognized that consistent provision of language support would not only enhance residents' comfort but also promote a more inclusive and supportive environment within the facility.During a follow-up interview with the Social Services Director (SSD) on December 4, 2025, at 2:22 PM, the SSD confirmed that a total of eight non-English speaking residents currently residing at the facility require interpreter services to effectively communicate with staff and participate in their plans of care. The SSD acknowledged that as of December 1, 2025, the facility lacked adequate interpreter services to meet residents' needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to ensure that physician's orders were followed for one of one resident (resident 11) reviewed for antibiotic use when the monitoring and documentation of intake and output (I&O) was not done as ordered by the physician.This failure resulted in an incomplete assessment and monitoring of Resident 11's hydration status and fluid balance while on the antibiotic (medication used to treat infections). Findings:A review of Resident 11's admission Record (contains medical and demographic information), indicated Resident 11 was admitted to the facility on [DATE], with diagnoses which included pneumonia (a lung infection), quadriplegia (paralysis affecting all four limbs), Chronic Obstructive Pulmonary Disease (a condition involving constriction of the airways and difficulty in breathing).During a review of Resident 11's care plan (an individualized plan for the medical care of a resident) titled, The resident has a Urinary Tract Infection r/t cloudy urine, lethargy (lack of energy) and generalized malaise (an overall feeling of being unwell), dated November 11, 2025, the care plan indicated, Goal.the resident will be free of symptoms of dehydration.Interventions.Encourage adequate fluid intake.During a review of Resident 11's care plan titled, The resident has potential for fluid deficit r/t [related to] PNA [pneumonia], dated October 4, 2025, the care plan indicated, Goal.The resident will be free of symptoms of dehydration.Interventions.Administer medications as ordered. Monitor/document for side effects and effectiveness. Educate the resident/family//caregivers on importance of fluid intake.Monitor/document/report PRN [as needed] any s/sx [signs and symptoms] of dehydration: decreased or no urine output.During a review of Resident 11's physicians orders, an order dated November 11, 2025, indicated Ertapenem sodium injection [an antibiotic] Solution reconstituted [the process of adding a diluent or solvent to a dry, powdered, or concentrated medication to create a usable liquid solution or suspension for administration] inject 1 gram [gm -unit of measure] intramuscularly [administered into the muscle] one time a day for UTI [urinary tract infection] for 5 [five] days with lidocaine [a numbing agent].During a review of Resident 11's physicians orders, an order dated November 12, 2025, indicated Monitor intake and output every shift for antibiotic use until 11/16/2025 [November 16, 2025].During a review of Resident 11's intake and output record titled, Documentation Survey Report V2, dated November 2025, the document indicated intake volumes were not documented by staff for three of ten (3 of 10) shifts between November 12, 2025, and November 16, 2025. Additionally, there was no output documentation found anywhere in Resident 11's medical record for the ten shifts between November 12, 2025, and November 16, 2025.During a concurrent interview and record review on December 3, 2025, at 2:47 PM, with the Director of Nursing (DON), Resident 11's intake and output record titled, Documentation Survey Report V2, dated November 2025, was reviewed. The DON acknowledged there were three of ten shifts where intake was not documented. Additionally, the DON acknowledged there was no output documentation noted for any of the ten shifts from November 12, 2025, through November 16, 2025. The DON stated nursing staff were supposed to document intake and output each shift as ordered by the physician, but they had not.During a concurrent interview and record review on December 3, 2025, at 2:48 PM, with the Corporate Medical Records Staff (CMR), Resident 11's entire electronic health record (EHR) was reviewed. The CMR acknowledged there were three shifts between November 12, 2025 and November 16, 2025, where input was not documented. The CMR stated output was not documented at all by staff, but should have been.During a review of the facility's policy and procedure (P&P) titled, Intake and Output, revised January 2025, the P&P indicated, It is the policy of this facility to maintain an intake and output record when needed to monitor residents for adequate fluid balance.Intake and output shall be recorded by each shift .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of two residents (Resident 3) reviewed for pressure ulcers (injury to skin and underlying tissues that develops as a result of prolonged pressure, shear, or friction) had a low air loss mattress (LAL mattress - a specialized mattress which is air filled and is designed to help prevent and treat pressure ulcers) which was programmed to Resident 3's weight.This failure resulted in the low air loss mattress to not have the most therapeutic effect for the prevention and treatment of pressure ulcers and for Resident 3 to have increased risk for the development of new pressure ulcers and a delay in wound healing.Findings:A review of Resident 3's admission Record (contains medical and demographic information), indicated Resident 3 was admitted to the facility on [DATE], with diagnoses which included heart failure, methicillin resistant staphylococcus aureus infection (an infection caused by an antibiotic-resistant bacteria), diabetes mellitus type 2 (a metabolic disorder characterized by persistent high blood sugar levels), and cellulitis of the left and right lower limbs (a bacterial infection of the skins deeper layers and underlying tissues).During a concurrent observation and interview on December 1, 2025, at 10:58 AM, Resident 3 was lying in bed on a low air loss mattress. The mattress was set to 360 pounds (lbs - unit of measure). Resident 3 stated he weighed approximately 275 lbs and that he was on the LAL mattress because he occasionally had bed sores and pressure ulcers.During a concurrent observation and interview on December 1, 2025, at 11:03 AM, with the Interim Director of Nursing (DON), the DON reviewed Resident 3's Electronic Health Record (EHR) and stated Resident 3 weighed 276 lbs. The DON stated the setting of the LAL mattress was supposed to be according to the physician's order and if there was no specific setting indicated in the physician's order, it was supposed to be set to the resident's body weight. The DON reviewed Resident 3's order for the LAL mattress and stated since there were no parameters for settings in the order, Resident 3's LAL mattress was supposed to be set to his body weight. The DON further stated the LAL mattress and its appropriate use was important to help prevent skin breakdown and to promote healing of wounds.During a concurrent observation and interview on December 1, 2025, at 11:08 AM, with the DON, Resident 3's LAL mattress was observed to be set to 360 lbs. The DON acknowledged the mattress was set to 360 lbs and stated the mattress was supposed to be set to 240 lbs. The DON then showed a label on the LAL mattress unit which stated Setting 240. The DON stated 240 lbs was the closest selectable level to the residents weight of 275 lbs. The DON further stated the wound care nurse puts the label on each LAL mattress to ensure the staff know what weight it was supposed to be programmed to. The DON stated she was not sure why Resident 3's LAL mattress was set incorrectly.During a review of Resident 3's EHR, the residents most recent weight documented in the vitals and weights portion of the EHR was recorded as 276 lbs on November 9, 2025.During a review of Resident 3's physician's orders, an order dated October 28, 2025, indicated, Low air loss mattress for itssue [tissue] load management, check placement, motor and setting every shift.During a review of Resident 3's care plan (an individualized plan for the medical care of a resident) titled, At risk for regression related to admitted with multiple pressure injuries, vascular ulcers.episodes of refusing to reposition, noncompliance with turning and repositioning and off loading of bilateral leg Dated October 28, 2025, the care plan included the intervention, Administer treatments as ordered and monitor for effectiveness.LAL mattress to promote tissue load management.During a review of Resident 3's Treatment Administration Record (TAR - a document used to record treatments administered to the resident), dated November 2025, the TAR indicated a task for, Low air loss mattress for itssue [tissue] load management, check placement, motor and setting every shift. For 26 out of 27 shifts between November 1, 2025, through November 30, 2025, staff documented that the LAL mattress was set to between 360 lbs and 370 lbs. Additionallyu, three shifts had blanks and were incomplete.During a concurrent interview and record review on December 3, 2025, at 2:35 PM, with the DON, Resident 3's TAR dated November 1, 2025, through November 30, 2025, was reviewed. The DON stated the nurses were supposed to document the current LAL mattress setting on the TAR and acknowledged the setting documented was between 360 and 370 lbs and was incorrect because the resident weighed 275 lbs in November 2025. The DON further stated nurses were supposed to be monitoring the residents weight and ensuring the LAL mattress was set per the residents weight, but it was not done.During a review of the facility's policy and procedure (P&P) titled, Low Air Loss, Alternating Pressure Pad or Mattress, dated January 2025, the policy indicated, It is the policy of this facility to prevent and treat pressure ulcers, alternate pressure under bony prominences and provide resident comfort.4. Low Air Loss mattress will be set up and serviced according to manufacturer's recommendations.During a review of the manual for Resident 3's low air loss mattress titled, [brand name] Operation Manual for Protekt Aire 4000DX/5000DX, (undated), printed December 1, 2025, the operators manual indicated, The Protekt Aire 4000DX/5000DX system is intended to reduce the incidence of pressure ulcers while optimizing patient comfort.Product Function.Press up or down buttons to select the correct patient weight.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to prevent the development and transmission of communicable diseases and infections, in a universe of 95 residents (Residents 1 to 95), when:1. Laundry Staff 1 (LS 1) and the Housekeeping Lead (HL) did not follow the manufacturer's guidelines for the disinfectant (DS 1) used to disinfect soiled laundry carts and soiled laundry barrels. In addition, the facility staff did not clean and disinfect the clean linen carts located in the resident hallways. This failure had the potential to cause the development and transmission of communicable diseases (an illness or infection that can spread from one person to another, or from a surface to a person) and infections to residents.2. Resident 82 who had contact isolation precautions (a set of infection control practices used to prevent the spread of germs that are transmitted by direct or indirect physical contact with a resident or the resident's environment) in place was not provided dedicated or disposable equipment such as a blood pressure cuff (an inflatable band wrapped around a resident's arm-or sometimes a thigh or wrist-to measure the resident's blood pressure), thermometer (a device used to measure the resident's temperature), stethoscope (a medical instrument used by healthcare professionals to listen to the internal sounds of a resident's body) or pulse oximeter (a device that measures the oxygen saturation level of a resident's blood and their heart rate).3. Room [room number] for Residents' 36, 21, and 59 was found with the following: 1. Under the beds there were various items had accumulated, including blankets, pillows, urine-soaked towels, tissues, food wrappers, medicine cups, ice cream cups, Styrofoam cups, straws, and dirty utensils.2. The trash can was overflowing with waste. 3. The floor was visibly dirty, covered with crumbs, sticky substances, and scattered pieces of paper. These failures had the potential to cause cross-contamination (the unintentional physical transfer of harmful bacteria, viruses, and fungi from one resident, object, or surface to another) and spread of infections to other residents, healthcare workers, and the wider Skilled Nursing Facility (SNF) environment.Findings:
1. During a Laundry Services and Facility Cleaning and Disinfection observation and interview on December 3, 2025, from 11:54 AM to 1:56 PM with the Housekeeping Lead (HL), Laundry Staff 1 (LS 1), Environmental Services Director (ESD), Certified Nursing Assistants 3, 4, 5, and 6 (CNAs 3, 4, 5, and 6) and the Infection Preventionist (IP), the HL stated that each hallway had two dirty linen receptacles which were on a plastic frame with net bags holding plastic trash bags with a plastic lid on the top. The HL stated she was responsible for cleaning and disinfecting the dirty linen receptacles on the 400 hallway but did not clean and disinfect the clean linen carts, I think the CNAs do that. The HL stated she used a disinfectant (DS 1) on the hard plastic surfaces of the dirty linen receptacles and kept the surfaces wet for 10 minutes before wiping the surface down or letting it air dry. The HL stated she sprayed the mesh bags with the DS 1 but was unable to keep the mesh bags wet for 10 minutes and she was not aware of the directions for the DS 1 indicated to use on non-porous surfaces (a material that is sealed and does not have any tiny holes, pores, or crevices) only. The HL stated when the dirty linen receptacles got full (Laundry Staff-LS- monitored the hallways hourly) the LS emptied all the full containers into a big black barrel on wheels which they took back to the laundry. The big black barrel was brought into the dirty side entryway of the laundry room where the LS donned (to put on) gown, gloves and goggles and sorted the dirty laundry into the dirty linen barrels.
LS 1 joined the observation and interview and stated heavily soiled linen were rinsed and then put into the dirty sorting barrels. LS 1 stated the dirty linen was placed into the washing machines which were preprogramed for different laundry items and told the machine what detergent to use. LS 1 stated the inside of the washing machine was wiped down after each wash cycle with DS 1 which was a neutral disinfectant. LS 1 stated she let the spray set for a couple minutes and then wiped it off. LS 1 stated she did not keep the item wet for 10 minutes as she did not remember DS 1's time frame for disinfection. LS 1 stated the clean linens were loaded into the clean barrel which was disinfected with DS 1 at least once per shift as were the dirty sorting barrels and LS 1 stated she did not keep the barrels wet for 10 minutes. The barrel with clean linen was brought to the dryer and loaded into the dryer and LS 1 stated she cleaned the inside and outside of the dryer door with DS 1 but did not keep the surfaces wet for 10 minutes.
The ESD joined the observation and interview at 12:31 PM, the ESD stated that surfaces need to remain wet for 10 minutes and should not be wiped before the 10 minutes were up. Additionally, DS 1 should not be used on mesh bags. LS 1 stated the laundry baskets took the clean dry clothes from the dryer to the folding table and laundry baskets were disinfected with DS 1 twice a shift and the folding table was disinfected after each load of laundry had been folded, I did not keep these surfaces wet for 10 minutes. LS 1 stated the folded laundry was stacked back into the basket and covered and taken to linen closet on the 400 hallway where the CNAs access the clean linen closet and stocked the clean linen carts. The ESD stated it was the CNAs responsibility to disinfect the covered clean linen carts in the hallways but there was no set schedule on when they should be disinfected or with what. The ESD stated the IP should know.
At 1:41 PM CNAs 3, 4, 5, and 6 joined the Facility Cleaning and Disinfection observation and interview and stated they were not aware they were responsible for disinfecting the clean linen carts in the hallway and thought the housekeeping staff were disinfecting the clean linen carts.
At 1:56 PM the IP joined the observation and interview, the IP stated she thought the housecleaning staff disinfected the clean linen cart weekly and did not know no one was disinfecting the clean linen carts. The IP stated the LS were required to use the disinfectant (DS 1) per the manufacturer's instructions and keep the hard non-porous surfaces wet for 10 minutes before wiping down.
A review of the [Company Name] Neutral Disinfectant [DS 1] Reference Sheet, undated, indicated, Disinfection Performance in Institutions (.Nursing Homes.) . with a 10-minute contact time [the specific amount of time the product must remain visibly wet on a surface to effectively kill the pathogens (bacteria, viruses, and fungi) listed on its label], this product is effective against the following organisms on hard, non-porous surfaces: .
A review of the facility's policy and procedure (P&P) titled,Cleaning & Disinfection of Environmental Surfaces, dated January 25, 2025, indicated, . 2. Non-critical surfaces will be disinfected with an EPA [Environmental Protection Agency]-registered intermediate or low-level hospital disinfectants according to the label's safety precautions and use directions. a. By law, all applicable label instructions on EPA-registered products must be followed. 3. Devices that are used by staff but not in direct contact with residents (e.g., computer keyboards, PDAs, etc.) shall be cleaned and disinfected regularly (according to facility schedule) by the environmental services staff and as needed by the nursing staff. 4. Manufacturers' instructions will be followed for proper use of disinfecting (or detergent) products including: a. Recommended use-dilution; b. Material compatibility; c. Storage; d. Shelf-life; and e. Safe use and disposal. 6. A one-step process and an EPA-registered disinfectant designed for housekeeping purposes will be used in resident care areas where: a. uncertainty exists about the nature of the soil on the surfaces (e.g., blood or body fluid contamination versus routine dust or dirt); or b. uncertainty exists about the presence of multidrug-resistant organisms on such surfaces. 7. Housekeeping surfaces (e.g., floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled. 8. Environmental surfaces will be disinfected (or cleaned) on a regular basis and when surfaces are visibly soiled.
2. During an observation and interview with Resident 82 on December 1, 2025, at 10:19 AM, a Contact Precautions sign, undated, posted outside Resident 82's room indicated, Contact Precautions Everyone Must: . use dedicated or disposable equipment. An isolation cart [a place to store contact precaution supplies] was located outside Resident 82's door with a sign posted to the isolation cart that indicated, Contact Isolation Precaution Cart Set-Up: . Disposable vital sign equipment . A review of the contents of the isolation cart indicated the top drawer contained two packages of instant ice pack, the second drawer contained isolation gowns, the third drawer contained more isolation gowns, the forth drawer contained two boxes of large exam gloves, and the fifth drawer contained two more boxes of large exam gloves. There was no indication of disposable or dedicated vital sign equipment. A review of the inside of Resident 82's room did not reveal disposable or dedicated vital sign equipment. Resident 82 stated the nurse brought the vital sign equipment into the room each day to take his vital sign readings.
During an interview with the Interim Director of Nursing (IDON) and the IP on December 1, 2025, at 11:20 AM, the IDON and the IP confirmed that Resident 82 lacked dedicated or disposable vital sign equipment, which should have been available.
A review of Resident 82's physician's order dated November 26, 2025, indicated, Order Summary: Contact isolation Carbapenem Resistant [a specific type of bacteria is not killed or inhibited by carbapenem antibiotics] Providencia Stuartii [a common bacterium found in the environment: soil, water, sewage] every shift for isolation precautions until [December 4, 2025] 23:59.
A review of the facility's policy and procedure (P&P) titled, Isolation - Categories of Transmission-Based Precautions, dated January 25, 2025, indicated, Policy Statement: Transmission-based precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents. Policy Interpretation and Implementation: . 2. Transmission-based precautions are additional measures that protect staff, visitors and other residents from becoming infected. These measures are determined by the specific pathogen and how it is spread from person to person. The three types of transmission-based precautions are contact, droplet and airborne. 5. When a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door and on the front of the chart so that personnel and visitors are aware of the need for and the type of precaution. A. The signage informs the staff of the type of CDC precaution(s), instructions for use of PPE, and/or instructions to see a nurse before entering the room. B. Signs and notifications comply with the resident's right to confidentiality or privacy. 6. When transmission-based precautions are in effect, non-critical resident-care equipment items such as a stethoscope, sphygmomanometer [blood pressure cuff], or digital thermometer will be dedicated to a single resident (or cohort [group] of residents) when possible.
3. During an observation on December 1, 2025, at 11:22 AM, in Room [room number], the room was found with the following:
1. Under the beds there were various items had accumulated, including blankets, pillows, urine-soaked towels, tissues, food wrappers, medicine cups, ice cream cups, Styrofoam cups, straws, and dirty utensils.
2. The trash can was overflowing with waste.
3. The floor was visibly dirty, covered with crumbs, sticky substances, and scattered pieces of paper.
During an interview on December 1, 2025, at 11:24 AM, with Resident 36, he stated the room had not been cleaned and the trash had not been removed for the past three days. Resident 36 further stated that due to his medications, which include diuretics (medications that increase the production of urine), he frequently urinates in towels because his urinal fills up quickly, and staff are not quick enough to dump it. Subsequently, he places these urine-soaked towels on the floor to avoid soiling his bed. Resident 36 further stated he uses tissues to wipe his nose and discards them on the floor due to the trash can being full and overflowing.
During an interview on December 1, 2025, at 11:26 AM with Resident 21, he stated, They did not clean my room for days now, look! pointing to the floor and under his bed.During an interview on December 1, 2025, at 11:28 AM, with Resident 59, he stated, Last time this room was cleaned was Friday morning. No one came to sweep and mop the floor over the weekend. Hopefully someone will come clean it today, but I haven't seen any housekeeper yet.
During an interview on December 1, 2025, at 11:30 AM with Certified Nurse Assistant 3 (CNA 3), CNA 3 stated room [room number] is dirty because the housekeeping staff did not clean the room and did not remove the trash over the weekend. CNA 3 further stated housekeeping had not been seen cleaning the room on the day of the interview either.
During an interview with the Environmental and Maintenance Services Director (EMSD) on December 2, 2025, at 9:20 AM, the EMSD acknowledged that the scheduled housekeeper did not clean the room this past weekend. The EMSD stated every room in the facility gets cleaned and moped at least once a day, sometimes multiple times depending on the residents' needs and housekeepers are expected to revisit and clean rooms that become messy throughout the day. The EMSD explained that the housekeeper 3 (HH 3) who is responsible for the cleanliness of rooms in 300-hall, was previously identified to have work performance deficiencies in the past and appropriate action was taken. The EMSD acknowledged that the room should have been cleaned and moped daily, and his expectations are that all housekeeping staff follow the daily cleaning schedule and facility's policy and procedures.
HH3 was not available for interview.
During an interview with the facility's Infection Preventionist (IP) on December 2, 2025, at 3:32 PM, the IP stated that her expectations are for the facility to be always maintained clean and for the staff to adhere to the daily cleaning schedule and follow facility's policies and procedures.
During an interview with the Operations Manager (OP) on December 3, 2025, at 1:58 PM, the manager specified that residents' rooms are required to be cleaned daily in accordance with the cleaning schedule and additionally as needed if they become dirty after the scheduled cleaning. The OP stated all staff must adhere to the facility's policies and procedures (P&P) to ensure a clean and sanitary environment for residents, staff, and visitors.
During a concurrent interview and record review on December 4, 2025 at 9:49 AM, with EMSD, the facility's P&P titled, Cleaning and Disinfection of Environmental Surfaces revised January 25, 2025, was reviewed.
The P&P indicated, Environmental surfaces will be cleaned and disinfected according to current CDC recommendations for disinfection of healthcare facilities and the OSHA Bloodborne Pathogens Standard.1. The following categories are used to distinguish the levels of sterilization/disinfection necessary for items used in resident care and those in the resident's environment: . c. Non-critical items are those that come in contact with intact skin but not mucous membranes: c1. Non critical environmental services include bed rails, some food utensils, bedside tables, furniture and floors. 2. Non critical services will be disinfected with an EPA-registered intermediate or low-level hospital that's infected according to the label's safety precautions and use directions . 6. A one-step process and an EPA-registered disinfectant designed for housekeeping purposes will be used in resident care areas where: a. Uncertainty exists about the nature of the soil on the surfaces (e.g. blood or body fluid contamination versus routine dust or dirt); or b. Uncertainty exists about the presence of multidrug resistant Organism on such surfaces. 7. Housekeeping surfaces (e.g. Floors, tabletops) will be clean on a regular basis when spills occur and when these surfaces are visibly soiled. 8. Environmental surfaces will be disinfected (or cleaned) on a regular basis and when surfaces are visibly soiled . 10. Disinfecting (or detergent) solutions will be prepared as needed and replaced with fresh solution frequently .13. Spills of blood and other potentially infectious materials will promptly be cleaned and decontaminated. Blood containment items will be discarded in compliance with federal regulations (i.e. OSHA Bloodborne Pathogens Standard). 14. If the spill contains large amounts of blood or body fluids, the visible matter will be cleaned with disposable absorbent material, and the contaminated materials discarded in an appropriate, labeled container.
The EMSD acknowledged the facility's P&P were not followed when room [room number] was found with various items accumulated under the beds, including blankets, pillows, urine-soaked towels, tissues, food wrappers, medicine cups, ice cream cups, Styrofoam cups, straws, dirty utensils, trash can overflowing with waste, visibly dirty floor covered with crumbs, sticky substances, and scattered pieces of paper. The EMSD admitted the dirty conditions in room present infection control issues, particularly to vulnerable residents, and acknowledged that the cleanliness standards were not met according to facility's P&P.

Based on observation, interview, and record review, the facility failed to provide special eating equipment in the form of an adaptive drinking aid for one sampled resident (Resident 89) when Resident 89, diagnosed with dysphagia (difficulty swallowing), was provided regular standard straws to drink thin fluids instead of a nosey cup (a cup with a U-shaped cutout on one side of the rim, which provides clearance for the nose and allows individuals to drink fluids without tilting their head or neck backward) during his lunch time meal. This failure had the potential to cause Resident 89 to choke, as standard straws deliver liquids quickly and encourage a head-back position that opens the airway. In contrast, the nosey cup encourages a chin-tucked position, reducing the risk of aspiration pneumonia an infection from fluids entering the lungs.Findings:A review of Resident 89's face sheet (a document that gives a summary of resident's information), undated, indicated an admission date of October 3, 2023. Resident 89 had diagnoses that included dysphagia.During a dining observation and interview with a Certified Nursing Assistant 1 (CNA 1) and Resident 89 on December 1, 2025, at 12:28 PM, Resident 89 was seated at a table in the dining room, and CNA 1 was helping him eat his lunch. A meal card on the table indicated that Resident 89 should use a nosey cup. However, he had a small milk carton with a regular straw and a regular cup of juice covered with cellophane, also with a regular straw poked through. CNA 1 helped Resident 89 drink using these regular straws and stated that Resident 89 did not have a nosey cup, but she did not know why.During an interview with the Dietary Supervisor (DS) on December 1, 2025, at 12:35 PM, the DS confirmed that Resident 89's meal card specified the use of a nosey cup, but this had not been provided. The DS acknowledged that she had not informed the Interim Director of Nursing (IDON), Resident 89's physician, or the Director of Rehabilitation (Dir/Rehab) that Resident 89 had declined and was no longer holding the nosey cup. In addition, the DS admitted to substituting regular straws without obtaining an Occupational Therapy (OT) assessment for straw use or requesting nursing staff to obtain a new dietary order from Resident 89's physician.A review of Resident 89's physician's order dated January 8, 2024, indicated, . nosey cup .During an interview with the IDON on December 1, 2025, at 12:40 PM, the IDON stated she had not been informed of Resident 89's decline and the subsequent need for a new OT evaluation for adaptive equipment, as well as a new physician's order reflecting the recommendations from the new OT evaluation. During an interview with the Dir/Rehab on December 4, 2025, at 10:51 AM, the Dir/Rehab stated Resident 89 should have been re-evaluated before replacing the nosey cup with regular straws, and a new physician's order reflecting the re-evaluation findings should have been obtained. The Dir/Rehab confirmed that her department had not been informed, and no re-evaluation of Resident 89's eating and drinking needs had been conducted.A review of the facility's policy and procedure (P&P) titled, Occupational Therapy . Evaluation and Recommendation of Feeding Adaptive Devices, undated, indicated, I. PURPOSE: To ensure safe, appropriate, and clinically justified evaluation, selection, and recommendation of feeding adaptive devices for residents who have functional limitations affecting self-feeding . III. POLICY STATEMENT: Occupational Therapy will evaluate residents with difficulty in self-feeding and recommend adaptive feeding equipment when clinically indicated. All recommendations will be evidence-based, individualized, documented, and coordinated with the interdisciplinary team (IDT). IV. PROCEDURE: A. Referral and Screening, A feeding adaptive device evaluation may be initiated through physician, nursing, dietary referral, or OT observation. B. Occupational Therapy Evaluation: Complete a comprehensive self-feeding evaluation including ROM [Range of Motion], strength, coordination, posture, cognition, and vision. Review SLP [Speech Language Pathologist] recommendations, IDDSI [International Dysphagia Diet Standardization Initiative] diet, and swallowing safety. Assess environmental factors such as seating, table height, and lighting. Trial appropriate adaptive feeding devices. C. Recommendation and Implementation: Device selection must be based on functional abilities and goals. Educate resident, caregiver, nursing staff, and family. Notify nursing and dietary of device recommendations. D. Documentation Requirements: Document evaluation findings and clinical justification. Devices trialed and resident response. Final recommendations and goals. Education provided and care plan updates.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure Resident 3's antibiotic medication (medication used to treat an infection) was labeled appropriately per facility's policy and procedure (P&P).This failure had the potential to result in administration errors, including administration of the wrong medication, wrong dose, wrong resident, or administration outside the ordered timeframe, thereby affecting Resident 3's safety.Findings:A review of Resident 3's admission Record (contains medical and demographic information), indicated Resident 3 was admitted to the facility on [DATE], with diagnoses which included heart failure, methicillin resistant staphylococcus aureus infection (an infection caused by an antibiotic-resistant bacteria), diabetes mellitus type 2 (a metabolic disorder characterized by persistent high blood sugar levels), and cellulitis of the left and right lower limbs (a bacterial infection of the skins deeper layers and underlying tissues).During a concurrent observation and interview on December 1, 2025, at 11:04 AM, with the Director of Nursing (DON), in Resident 3's room, Resident 3 was lying in bed and had an intravenous (IV - medication administered into the veins) bag of vancomycin (antibiotic medication) which had already been administered and was hanging at his bedside. The vancomycin antibiotic had no pharmacy label on it and had a label attached to it which indicated medication added, with the residents last name, room number, date, and time indicated on it. The medication added, label was left blank where it indicated, drug, amount, added by, rate, and base sol'n [solution]. The DON stated the IV antibiotic was not labeled correctly and only had the patient's last name, date and time of administration, and room number indicated on it.During a follow up interview on December 1, 2025, at 11:11 AM, with the DON, the DON stated the nurse who administered the vancomycin IV antibiotic was supposed to remove the pharmacy label from the foil pouch the vancomycin came in and apply it to the vancomycin bag once removed from the pouch, but it was not done.During an interview on December 3, 2025, at 11:50 AM, with the Consultant Pharmacist (CP), the CP stated IV vancomycin comes in a foil pouch which has a patient specific label affixed to the outside of the foil pouch. The CP further stated when the medication bag is removed from the foil pouch for administration to the patient, staff was supposed to remove the patient specific pharmacy label on the foil pouch and apply it to the medication bag.During a review of the facility's policy and procedure (P&P) titled, Medication Administration - Intravenous (IV) Administration of Drugs via Central Venous Catheters (CVC) or Peripherally Inserted Central Catheters (PICC), dated January 2025, the P&P indicated, .8. IV medications must be labeled in accordance with established procedures governing all labeling IV medications and IV solutions.During a review of the facility's P&P titled, Labeling and Storage of Drugs, revised January 2025, the P&P indicated, It is the policy of this facility that medications and biologicals are labeled in accordance with facility requirements, state and federal laws.1. Each prescription medication label includes: resident's name, specific directions for use, including route of administration, strength of medication. Injectables: strength per ml (cc) and the amount to be given in mls [milliliters - unit of measure] equivalent on label, physician's name, date medication is dispensed, quantity, expiration date, name, address, and telephone number of provider pharmacy, prescription number, accessory label indicating storage requirements and special procedures. Example: shake well; Take on empty stomach.container number and total number of containers.when multiple containers are dispensed for one prescription.

Based on interview, and record review, the facility failed to protect against physical abuse for one of three sampled female residents (Resident 1) when a male resident (Resident 2) kissed Resident 1 on the mouth and fondled her (to touch in a sexual way) when Resident 1 did not have the capacity to consent.
This failure had the potential to cause Resident 1 to suffer psychological distress, anxiety, and shock.
Findings:
An unannounced visit was made to the facility on January 29, 2025, at 10:45 AM, to investigate a facility reported incident regarding an allegation of physical abuse.
A review of Resident 1 ' s face sheet (a document that gives a summary of resident ' s information), undated, indicated an admission date of January 4, 2021. Resident 1 had diagnoses that included dementia (a brain disorder that causes a decline in mental abilities, such as memory, thinking, reasoning, and problem-solving) and quadriplegia (a condition characterized by the loss or severe impairment of motor function, sensation, and nervous system functions in all four limbs--arms and legs).
A review of Resident 1 ' s physician ' s history and physical (H&P-a formal assessment of a patient's health that includes a medical history, physical exam, and a summary of any testing), dated March 30, 2024, indicated, Patient Informed of Medical Condition: No, Patient Capable of Admitting Self: No, Patient Capable of Making Decisions: No.
During an interview with Resident 2 on January 29, 2025, at 11:41 AM, Resident 2 stated he kissed Resident 1 on the mouth and put his hands on Resident 1 ' s breasts. Resident 2 stated Resident 1 had asked him to stop, so he stopped and that was when the nurse told him to step away from Resident 1, so I walked away.
During an interview with Resident 1 on January 29, 2025, at 12 PM, Resident 1 stated she had called Resident 2 over as he passed in the hallway and kissed him. Resident 1 stated Resident 2 was receptive to her advance and began touching her breast. Resident 1 stated she told Resident 2 that was a far as he could go, and Resident 2 stopped. Resident 1 stated that was when the nurse came and told Resident 2 move away from her. Resident 1 stated she had wanted the sexual contact and Resident 2 had been receptive to her.
During an interview with a Certified Nursing Assistant (CNA 1) on January 29, 2025, at 12:30 PM, CNA 1 stated she was standing at the nursing station, the 400 hallway was behind her, and as she turned around, she saw Resident 2 leaning over Resident 1 with his hand down inside her shirt. CNA 1 stated Resident 1 was in her Geri chair (large, padded chair with a wheeled base) positioned in the hallway and Resident 2 was leaning over her and she said to Resident 2 to step away, back away from Resident 1. CNA 1 stated Resident 1 and Resident 2 looked up at her with shocked expressions and did not say anything and Resident 2 began walking down the hallway away from Resident 1. CNA 1 stated she stood next to Resident 1 to provide protection and flagged down another staff person to get the Charge Nurse for the 400 hallway, the Charge Nurse came, and she gave report of the situation. CNA 1 stated Resident 1 seemed to laugh it off as the Charge Nurse asked her questions about what had happened, and Resident 1 did not appear to be upset by the situation.
During an interview with the Director of Nursing (DON) on January 29, 2025, at 1:43 PM, the DON stated Resident 1 did not have the capacity to consent to sexual contact and sexual contact had occurred between Resident 1 and Resident 2. The DON stated the facility had not protected Resident 1 from physical abuse.
A review of the facility ' s policy and procedure (P&P) titled, Resident Rights, dated December 2021, indicated, Policy Interpretation and Implementation:1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity; c. be free from abuse, neglect, misappropriation of property, and exploitation .

Based on observation, interview, record review, and facility policy review, the facility failed to provide facial grooming for 1 (Resident #76) of 2 sampled residents reviewed for activity of daily living (ADL) care.
Findings included:
A facility policy titled, ADL, Services to carry out, reviewed 12/2023, revealed, It is the policy of this facility that residents are given the appropriate treatment and services to maintain or improve his/her abilities. The policy revealed, 2. Residents who are unable to carry out activities of daily living (ADL) will receive necessary services to maintain, including Grooming.
An admission Record indicated the facility admitted Resident #76 on 09/26/2024. According to the admission Record, the resident had a medical history that included diagnoses of hemiplegia and hemiparesis (muscle weakness and paralysis on one side of the body) following a cerebral infarction (a stroke) and complete traumatic trans metacarpal amputation of left hand.
An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/13/2024, revealed Resident #76 had moderate impairment in cognitive skills for daily decision making and had short-term and long-term memory problems per a Staff Assessment of Mental Status (SAMS). The MDS indicated the resident did not exhibit any behavior of rejecting care during the assessment timeframe. Per the MDS, the resident was totally dependent on staff for personal hygiene needs.
Resident #76's care plan included a focus area initiated 08/20/2024, that indicated the resident had an ADL self-care performance deficit. The care plan indicated that the resident was totally dependent on staff for personal hygiene.
Resident #76's Skin Monitoring: Comprehensive CNA [certified nurse aide] Shower Review, dated 11/08/2024 and completed by CNA #9, indicated the resident had a bed bath. T
During an interview and observation on 11/11/2024 at 9:45 AM, Resident #76 was observed with facial hair on their chin, cheeks, and upper lip approximately 1/4 inch long. When asked if they liked having facial hair, Resident #76 shook their head, indicating that they did not.
During an interview on 11/12/2024 at 10:16 AM, Resident #76's family member stated the staff shaved the resident about once a month.
On 11/13/2024 at 1:43 PM, CNA #9 stated that it was her first time to work with Resident #76 on 11/08/2024. She stated that she did not know if the resident preferred to be shaved or not. She stated she did not shave Resident #76 on 11/08/2024 during the resident's bed bath.
On 11/14/2024 at 7:54 AM, Licensed Vocational Nurse #7 stated that staff should know the preferences of the residents, and if they did not know, they should ask. She stated Resident #76 liked to be clean shaved.
On 11/14/2024 at 8:32 AM, the Director of Nursing stated that whatever the resident could not do, the staff should do for them. He stated that staff should wash the residents' hair and offer to shave.
On 11/14/2024 at 10:53 AM, the Administrator stated that staff should assist the resident with bathing. She stated the staff should offer to shave the resident during that time. She stated that the staff should know the residents' preferences.

Based on interview, record review, and facility policy review, the facility failed to ensure the preadmission screening and resident review (PASRR) was accurately completed for 1 (Resident #44) of 3 sampled residents reviewed for PASRR requirements. Specifically, Resident #44 had a serious mental illness (SMI) that was not captured in their Level I PASRR screening.
Findings included:
A facility policy titled, PASRR Completion Policy, reviewed 12/2023, specified, The Center will a [sic] make sure that all admissions have the appropriate Patient Assessment and Resident Review (PASRR) completed. The policy specified, 1. Center Administrator will designate the medical records to make sure that the [PASRR]and/or Level of Care (LOC) is done on all potential residents. If the referral indicates anything which might constitute an SMI or ID [intellectual disability], the PASRR must be completed prior to admission.
An admission Record revealed the facility admitted Resident #44 on 08/02/2024. According to the admission Record, the resident had a medical history that that included diagnoses of bipolar disorder (onset 08/02/2024) and anxiety disorder (onset 08/02/2024).
An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/08/2024, revealed Resident #44 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated the resident had severe cognitive impairment. The MDS indicated Resident #44 had active diagnoses to include anxiety disorder and of manic depression (bipolar disease).
Resident #44's care plan included a focus area initiated 08/05/2024, that indicated that the resident had a mood problem related to bipolar disorder and anxiety disorder. Interventions directed staff to refer the resident for behavioral health consultations as needed.
Resident #44's physician orders revealed an order dated 08/04/2024, for quetiapine fumarate (an antipsychotic) oral tablet 24 milligrams, one tablet by mouth at bedtime for bipolar manifested by mood swings.
Resident #44's Preadmission Screening and Resident Review (PASRR) Level I Screening, dated 08/02/2024, indicated that the resident had no diagnosed SMIs and did not have a suspected mental illness.
During an interview on 11/13/2024 at 3:35 PM, the Social Services Director stated that the hospital completed the resident's Level I PASRR screening. She stated that she was not sure what the process was for the facility staff to review Level I PASRR screenings for accuracy or who was responsible for reviewing them.
During an interview on 11/13/2024 at 3:57 PM, the Medical Records Resource stated that the hospital created Resident #44's Level I PASRR screening. She stated that she did not know of any process to review hospital Level I PASRR screenings for accuracy or who was responsible for reviewing them.
During an interview on 11/13/2024 at 12:57 PM, the Director of Nursing stated that he was not sure if there was anyone in the facility who reviewed Level I PASRR screenings from the hospital for accuracy, but he believed that it was the responsibility of medical records staff.
During an interview on 11/13/2024 at 1:13 PM, the Administrator stated that medical records staff were responsible for PASRR accuracy.

Based on interview, record review, and facility policy review, the facility failed to transcribe a physician order from an outside ear, nose, and throat (ENT) physician for 1 (Resident #70) of 1 resident reviewed for communication sensory concerns.
Findings included:
A facility policy titled, Physicians, Consulting, revised 12/2023, revealed, Purpose To promote continuity of care. The policy revealed, 5. If treatment or medications are ordered by the consulting physician, it will be communicated to a licensed staff to carry out the new treatment order. 6. Medication/treatment will be transferred to MAR [medication administration record]/TAR [treatment administration record], ordered from pharmacy/other, and treatment or medication regime initiated, and family and/or resident informed of change in plan of care.
An admission Record indicated the facility admitted Resident #70 on 02/07/2024. According to the admission Record, the resident had a medical history that included diagnoses of intraspinal abscess and granuloma and muscle weakness.
A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/01/2024, revealed Resident #70 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment.
A physician note, dated 10/02/2024, revealed Resident #70 was seen by a physician assistant for diminished hearing, nasal congestion, throat congestion/clearing, and stuffy ears. According to the physician note, the plan included use an earwax removal aid drops twice a day for four days in the resident's left ear.
Resident #70's MAR for the timeframe from 10/01/2024 through 10/31/2024 revealed no evidence of an order that directed staff to instill drops in the resident's left ear.
On 11/11/2024 at 11:13 AM, Resident #70 stated they were seen by an ENT physician a month ago and the facility did not administer the ear drops as ordered.
On 11/13/2024 at 7:52 AM, the Social Services Director (SSD) stated the ENT physicians came in every nine weeks. She stated the physicians were able to write orders. She stated that the orders were given to the nurse and the nurse placed (transcribed) the orders into the computer.
On 11/13/2024 at 9:51 AM, Registered Nurse (RN) #6 stated that orders were given to the charge nurse on the hall or the desk nurse. She stated that nursing staff were supposed to follow up on the orders. She stated that the RN supervisor should be following up as well to ensure the orders were completed. RN #6 reviewed Resident #70's medical record and stated that the order was not carried out. She stated that the order should have been carried out and stated that there was a delay of care.
On 11/13/2024 at 10:53 AM, Licensed Vocational Nurse (LVN) #7 stated that when the physician completed their rounds, the physician found a floor nurse to give the orders to. She stated that from there, the orders were carried out and put (transcribed) into the medical system. She stated that she remembered the physician giving her the orders for the day, but not sure if there were any orders for Resident #70. She stated she did not recall transcribing an order for Resident #70. LVN #7 stated that the orders should be put in that same day and if not, they could pass it on to night shift. She reviewed resident #70's medical record and the order summary for October 2024 and November 2024 and stated that she must have just not transcribed the order in the computer.
On 11/13/2024 at 3:25 PM, the Director of Nursing (DON) stated that the staff should work with the ancillary physician and follow through with what the physicians asked of the facility.
On 11/13/2024 at 3:32 PM, the Administrator stated that she expected the nursing department to follow up with the order to clarify if needed, and to carry out the order. She stated that she expected the order to be put in the day the order was received or the following day. She stated that the order from the ENT was not carried out.
On 11/14/2024 at 1:51 PM, the DON stated the facility was unable to produce the physician orders that were given to the nurse on duty.

Based on interview, record review, and facility policy review, the facility failed to ensure staff administered medication as ordered for 1 (Resident #16) of 5 sampled residents reviewed for unnecessary medications.
Findings included:
An undated facility policy titled, Medication Administration - General Guidelines specified, Medications are administered in accordance with written orders of the attending physician.
An admission Record revealed the facility admitted Resident #16 on 01/28/2024. According to the admission Record, the resident had a medical history that included a diagnosis of hypertensive heart disease with heart failure.
A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/16/2024, revealed Resident #16 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment.
Resident #16's Order Summary Report, for active orders as of 11/13/2024, revealed an order dated 01/28/2024, for bumetanide oral tablet 2 milligrams, give one tablet by mouth one time a day for congestive heart failure, hold for systolic blood pressure (SBP) less than 110 millimeters of mercury (mmHg).
Resident #16's medication administration record (MAR) for the timeframe from 10/01/2024 through 10/31/2024, revealed evidence to indicate Licensed Vocational Nurse (LVN) #2 administered bumetanide 2 mg to the resident when the resident had a SBP of 102 mmHg on 10/02/2024.
During an interview on 11/13/2024 at 1:37 PM, LVN #2 stated that staff were supposed to check that the resident's blood pressure was within parameters before administering medication. She stated that Resident #16's MAR indicated the resident received their bumetanide when the resident's blood pressure was outside of the physician-ordered parameters. She stated that she had been a nurse long enough to know not to do that.
During an interview on 11/13/2024 at 3:10 PM, Medical Doctor #10 stated staff should have followed the parameters set by the physician with regards to medication administration.
During an interview on 11/14/2024 at 12:57 PM, the Director of Nursing (DON) stated that nurses should follow the physician-ordered parameters with regards to medication administration.
During an interview on 11/14/2024 at 1:13 PM, the Administrator referred to the DON regarding medication administration and physician-ordered parameters.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement a care plan (a document outlining how to best care for a resident and meet their needs) for one of three sampled residents (Resident 3) after Resident 3 suffered a fall with injury.
This failure had the potential for Resident 3 to suffer a subsequent fall that could result in another injury or worsening of Resident 3's current injury to his left ribs.
Findings:
During a review of Resident 3's admission Record (a document with basic client information), the admission Record indicated, Resident 3 was admitted to the facility on [DATE], with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD - a disease of the lungs that causes air-flow blockage and breathing-related problems), Epilepsy (abnormal electrical brain activity, also known as a seizure) and History of Falling (resident has fallen in the past).
During an observation on February 8, 2024 at 9:48 AM, in the facilities 400 hallway, Resident's 3 room was located at the end of the 400 hallway and not close to the nurses station.
During a concurrent observation and interview on February 8, 2024, at 9:52 AM Resident 3's room with Certified Nursing Assistant (CNA 1) Resident 3's call light (device used to call for help and assistance) was tied to the bed rail and hanging near the floor behind his head and not accessible to Resident 3. CNA 1 stated Resident 3 could not reach the call light and Resident 3 could decide to get up to call for help and fall again.
During a concurrent interview and record review on February 8, 2024, at 11:00 AM with Licensed Vocational Nurse (LVN 1), Resident 3's Care Plan dated January 31, 2024 was reviewed. The Care Plan indicated, .Interventions Attach call light to bed within access of resident .Place resident close to nursing station for close observation . LVN 1 stated Resident 3's care plan was not fully implemented . She stated Resident 3's room is not close to the nurse's station and the resident should be able to access his call light from his bed. The LVN 1 further stated, Resident 3 would have difficulty requesting help if he needed it and could try to get up and fall again.
During a concurrent interview and record review, on February 8, 2024, at 11:30 AM, with Registered Nurse (RN), the facility policy and procedure (P&P) titled, Care Planning, undated, was reviewed. The P&P indicated, Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .1. The interdisciplinary Team (IDT) .develops and implements a comprehensive, person center care plan for each resident . RN stated, the purpose of a care plan is to implement interventions to prevent another fall. RN further stated Resident 3 could have fallen again if he was not able to reach the call light and him being far away from the nurses station makes it hard for staff to observe Resident 3 and monitor him for falls.
During a review of the facility's policy and procedure (P&P) titled, Falls-Clinical Policy, undated, the P&P indicated, .Treatment/Management 1. Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the psychosocial wellbeing of 1 out of 3 residents (Resident 1) when the facility put a screw on the window in Resident 1's room to prevent widow from opening all the way.
This failure placed resident 1 at risk of depression, and a decline in psychosocial harm when Resident 1 stated he does not feel safe with screw is in the window.
Findings:
An unannounced visit was made to the facility on December 27, 2024, at 10:25 AM to investigate a complaint regarding Quality of Care/Treatment and Physical Environment.
During a review of resident 1 ' s admission Record (general demographics), the document indicated resident 1 was admitted to the facility on [DATE], with a diagnosis to include Muscle weakness, other lack of coordination, low back pain, Encephalopathy (a group of conditions that cause brain dysfunction).
During an interview with Resident 1, on December 27, 2023, at 10:45 AM, he stated he is doing well and is just concerned about the window. He states what happens if there is a fire? We could all get killed, there is no way to get out if the door or the hallway is on fire, and they cannot get to us, I do not feel safe with screw on window.
During an interview with Administrator (AD) on December 27, 2023, at 10:30 AM, he stated to maintain temperature regulation for the facility all windows are secured and have a lock. There are other escape routes. He states all resident windows are secure with a screw. He stated he is not sure if it ' s in [NAME] 22 but he will have the Building director talk with me.
During an interview with Building and Facilities director on December 27, 2023, at 10:35 AM, he stated that when he spoke with Life and Safety, he was told that all windows can be secured, even with a screw, to not disrupt air balance. He let me know he reached out to Life and safety to email him the policy where it states it is ok to secure windows in that manner.
During an interview with DON (Director of Nursing) on December 27, 2023, at 11:00 AM, she stated she is aware all windows are secured with a screw and in case of a fire there are escape routes throughout facility. States she is not sure why there are screws om windows.
During an interview with maintenance on December 27, 2023, at 12:21 PM, he stated he is aware the windows are shut with a screw, states yes I am aware they are states we have a problem maintain the right temperature during the summertime because some residents open the windows. When asked should they be shut with a screw? He states it keeps the residents from opening the windows and disrupting the air balance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to remove a building hazard, a threshold (a strip of wood, metal, or stone forming the bottom of a doorway and crossed in entering a house or room) that leads to the patio and is used by residents and families creating a hazard which poses a risk for falls.
This failure placed two out of three residents (Resident's 1 and 2) at risk for severe injuries due to falls.
Findings:
An unannounced visit was made to the facility on November 27, 2023, at 1:19 PM, to investigate a complaint regarding quality of care and Accidents.
During review of resident 1's admission Record (general demographics), the document indicated resident 1 was admitted to the facility August 1, 2023, with diagnosis to include Muscle weakness, Hemiplegia(paralysis on one part of the body) and Hemiparesis (weakness or the inability to move on one side of the body) affecting right dominant side following Cerebral Infarction(a lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off).
During a review of resident 1's progress note, (An ongoing record of a patient's illness and treatment) dated November 19, 2023, at 7:05 AM, the document by Licensed Vocational nurse (LVN 1), it indicated, Another resident was yelling for help. I went to the patio resident was lying on her right side, her right leg was wrapped around the wheelchair that was behind her, she was fully clothed. This happened in the patio entrance into the facility. Resident stated she was trying to get back into the facility and when she reached the doorknob she fell out of her chair, she has a hematoma (a localized swelling that is filled with blood caused by a break in the wall of a blood vessel(a network of tubes through which blood is pumped around the body) on her right forehead with 8/10 pain, res on observation could move all extremities, had PERLA (an acronym for pupils are equal, round and reactive to light and accommodation. Healthcare providers use the PERRLA eye test to check if your pupils look and function as they should), hand grasps bilat weak. She was lifted off floor via 2 persons assist and placed back into her wheelchair. Doctor was notified and res was sent to the ER (emergency room) for further eval. BP (blood pressure, the pressure of blood pushing against the walls of your arteries) 183/78, r (respiratory)85, O2 Sat (measures the percentage of oxyhemoglobin (oxygen-bound hemoglobin) in the blood) 96, temp (temperature) 97.5.
During an interview with resident 1, she stated I fell trying to go to the patio, that thing on the floor to the patio is hard to get over it . She sated she hit her face and her leg has bruises (skin discoloration from damaged, leaking blood vessels underneath your skin).
During review of resident 2's admission Record, the document indicated resident 2 was admitted to the facility March 5, 2019, with a diagnosis to include acquired absence of right leg below knee, Hemiplegia and Hemiparesis affecting right dominant side.
During a review of resident 2's progress note dated November 26, 2023, at 9:27 PM, the document by LVN 2, it indicated, resident had unwitnessed fall at 2020 hours. It appears that resident was attempting to come back in the facility from smoking and his w/c (wheelchair) tipped backward. Resident hit the back of his head on the concrete. Sent resident to ER. Resident had 2 seizures (a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements (stiffness, twitching or limpness), while awaiting paramedics. First seizure lasted 20 seconds. Second seizure lasted 40 seconds. Paramedics arrived and transported resident to hospital at 2100 .
During an interview with resident 2, he stated he is fine and has no issues. States he does not have issues with his wheelchair. States yeah I fell but does not remember when or how. We were by the door, and he wheeled himself through the door without difficulty.
During an interview with RN 1 (registered nurse) on November 27, 2023, at 1:40 PM, she stated she is aware of the door threshold by the patio. States she has told maintenance to take care of it but they haven't sates overall everything in the facility is good .
During an interview with [NAME] AD (administrator) on November 27, 2023, he stated He stated the threshold was installed a couple of months ago. He stated that they had an IDT (interdisciplinary team) meeting today regarding the threshold on the patio door. It was decided that it will be taken out . On the same day [NAME] notified me at 2:20 PM the threshold to the patio has been taken out . Visually verified.
During record review on November 27, 2023, at 2:50, review of Policy and Procedures Titled Falls and Fall Risk, Managing dated March 2018, the document indicated Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling . It also indicates , 1. Environmental factors that contribute to the risk of falls includes: d) obstacles in the footpath.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a request for documents was fulfilled in a timely manner for two of three sampled residents (Resident 1 and Resident 2) when the facility did not provide the requested documents within the timeframes specified in their policies.
This failure had the potential to result in the Resident ' s denial of a timely due process.
Findings:
An unannounced visit was made to the facility on November 15, 2023, at 11:00 AM, to investigate a complaint regarding quality of care.
During a review of the Medical Records Requests:
1. Resident 1 had a letter sent to the facility by [name of legal firm] which indicated the facility received a request for release of Resident 2 ' s medical records on October 24, 2023. Review of the confirmation fax document (states when the document was sent to the legal firm) indicated the medical records for Resident 1 was sent on November 14, 2023 (sixteen days after they received the typewritten documents request) to the [name of legal firm.]
2. Resident 2 had a letter sent to the facility by [family member] which indicated the facility received a request for release of Resident 2 ' s medical records on October 23, 2023.
There was documented evidence that the medical records were released and sent to the [family member] on October 27, 2023.
During an interview with the Medical Records representative (MR) on November 15, 2023, at 11:15 AM, MR indicated she received the medical records request but had been advised by Corporate office (CO) that all medical records request are to be sent to their office for approval and she waited for confirmation from CO to release the medical records. MR stated she was aware that per [NAME] 22 she was to release medical records within 2 business days.
During an interview with the Administrator (AD), on November 16, 2023, at 9:00 AM, he stated they do send medical records request to CO and that he will check and make sure medical records for [name of legal firm] were released.
A review of The Facility Policy and Procedure titled Release of Information, Minimum Necessary Use undated, indicated Subpoena and/or court orders will be processed in accordance with the current state law and facility policy.

F642
Based on interview and record review, the facility failed to ensure proper security measures were in place to protect the use of an electronic signature. When (Licensed Vocational Nurse LVN1) used (Registered Nurse RN 1), electronic signature to sign a (Minimum Data Set MDS) verifying the MDS is complete for 66 residents.
This failure had the potential to cause inaccuracies in the completed comprehensive assessment in the MDS's for 66 clinically compromise residents.
During an interview on October 4, 2023, at 11:22 AM, with the Activities Director, (Activities Director focuses on creating activities that enrich participants' lives with physical and cognitive exercise and socialization through recreational activities such as sports, dancing, arts, and crafts). The Activities Director stated she assesses residents by filling out the Minimum Data Set Assessment (MDS- a computerized resident assessment instrument) States she goes to the residents' room and uses a paper form, then goes on PCC (PointClickCare, a cloud-based healthcare Software provider) to document and keeps paper form in a binder in her office. She then signs off with her password. She stated if her password does not work, she will talk to DSD (Director of Staff Development) or administrator to reset her password. She also stated she had an in-service and signed a paper that state no sharing of password.
During an interview on October 4, 2023, at 1131 AM, with DSD Assistant, she stated she does the supplemented training. She stated she did the training because some passwords were not being protected, that there were issues with information that needs to be shared with other and things were being signed off . Stated that if her password is not working, she would contact information support at Corporate Office through email. States staff usually go to nursing supervisor or administration.
During an interview on October 4, 2023, at 1145 AM, with Dietary Supervisor, she stated her MDS documentation part is the letter K, Swallowing and Nutritional status. Stated she does the assessment in the residents' room, once the assessment is done and completed, she documents on PCC, she then signs at the end using her passcode. States if her passcode does not work, she will let administration know. She stated she knows not to share her passcode because that is her signature, and it was told to her on orientation by staff development.
During an interview on October 4, 2023, at 1200 PM, with MDS nurse, she stated,
her passcode needed to be reset and she asked Medical Records Director, who created a new profile instead of resetting password. States she does her resident assessments in the rooms then goes to the office and enters data and signs assessment she did. States then the DON (director of nursing) signs for the RN (registered nurse). States he makes sure her sections are completed.
During an interview on October 4, 2023, at 1215 PM, with DON, she stated she has not done MDS as an MDS nurse. States she understands there were 66 modifications during September 6, 2023, through September 12, 2023, to make a correction or an adjustment. States that if her passcode was used, she would report to administration that someone used her passcode. She stated she has been employed for a year and in orientation they talked to her about not sharing her passcode.
During a concurrent interview on October 4, 2023, at 12:52 PM, with Administrator and DON, the administrator stated his knowledge base of the MDs is the same as a High-level Rehab Director (Director of Rehabilitation). States the Rehab Director puts in the minutes in the MDS, and the rehab Director makes sure the therapy department minutes are accurate before sending them over. States there are 66 modifications on MDS to make sure they are accurate and to make sure an accurate RN signature. Stated they were under the direction of RAI (Resident Assessment Instrument) to modify signatures. Stated before doing that they went to RAI or probably a third-party auditor. Stated the in-service of Policy and Procedure review on September 29, 2023, was to review MDS completion and Passwords and User ID codes. Stated he will have staff come in at all hours to ensure all staff are in serviced.
During an interview on October 4, 2023, at 1:00 PM, with a ADON (Acting Director of Nursing), he stated he has been employed for 3 months. Stated he was ADON from July 5, 2023, through September 24, 2023. He stated that while he was acting ADON, he did not do anything with MDS because he probably got 1.5 hours of training. Stated his understanding of signing off the MDS is to make sure MDS is complete since this investigation started. Stated they told him he was signing that each section was completed. His understanding of how his signature got on the MDs was when he raised the flag that his password was being reset. He stated that his password was reset 2 weeks into him being ADON and in July his password was reset a few times. States that in August while he was on vacation his password was also reset a few times. States that it was brought this attention by the medical records that there was 112 pages of documentation with his signature. He states his understanding if his password does not work, he would notify medical records then she would reach out to Corporate office resources, and they would reset it. He stated that he believes it was Medical Records Director. He stated that if he was not able to log on to PCC and would get a notification to reset, it was reset to a default and that way LVN 1 MDS resource, was able to sign off all the MDS under his name.
During a review of the facility's Policy and Procedure titled Electronic Signatures and Electronic Orders revised April 2021, the policy and procedure indicated the HCP will receive an individual identifier access code from an appropriate administrative person. The access code is for his/her use only.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of 18 sampled resident (Resident 46) individual needs and preferences were accommodated when a Resident 46 was not able to reach the pull cord for the overhead light to adjust the lighting according to her needs.
This failure led to Resident 46 being dependent on staff and further decreasing her level of independent functioning.
Finding:
During a review of Resident 46 face sheet (a facility document which contains basic information about the resident), indicated Resident 46 was admitted to the facility on [DATE], with diagnoses which included diabetes mellitus (high blood sugar), generalized muscle weakness, abnormalities of gait and mobility (not able to walk and move normally), major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), and insomnia (difficulty sleeping).
During a concurrent observation and interview on December 9, 2021, at 9:10 AM, with Resident 46, in the resident's room, Resident 46 stated she would like her light turned on. Resident 46 stated staff sometimes leave the light on at night. Resident 46 was asked if she can reach the pull cord for the overhead light, Resident 46 tried to grab the pull cord tied to the bed side rail but could not reach it.
During a concurrent observation and interview on December 9, 2021, at 9:21 AM, with Certified Nurse Assistant (CNA 1), CNA 1 stated the long cord attached to the light switch is so Resident 46 is able to turn the overhead light on and off herself. Resident 46 then showed CNA 1 she could not reach the pull cord for light switch. CNA 1 stated Resident 46 can not reach the pull cord and adjusted the pull cord so Resident 46 could reach it.
During a review of the facility's policy and procedure titled, Accommodation of Needs - Quality of Life, dated August 2009, indicated, 3. In order to accommodate individual needs and preferences, adaptations may be made to the physical environment, including the resident's bedroom and bathroom, as well as the common areas in the facility. Examples of such adaptations may include: e. Installing longer cords or providing remote controlled overhead or task lighting so that they are easily accessible .

Based on interviews, and record review, the facility failed to transmit Minimum Data Set (MDS) assessments (a federally mandated process for assessing resident's functional capabilities and health needs) within the required timeframe parameters for 20 out of 22 sampled residents.
This had a potential to cause harm due to missed tracking and trending of changes and/or declines in a resident's condition.
Findings:
During a record review on December 8, 2021, at 9:10 AM, it was noted that there were MDS assessments that had not been transmitted and were still in progress for Resident 29, Resident 60, Resident 9, Resident 28, Resident 7, Resident 14, Resident 61, Resident 13, Resident 25, Resident 8, Resident 3, Resident 53, Resident 15, Resident 26, Resident 12, Resident 54, Resident 6, Resident 30, Resident 27 and Resident 11.
During an interview on December 8, 2021, at 10:00 AM, with the Administrator (ADM), The ADM stated that the facility had been having trouble keeping an MDS Coordinator and there hadn't been one for quite some time and he was aware that a lot of the MDS assessments had not been completed or transmitted.
During an interview on December 8, 2021, at 2:00 PM, with the MDS Consultant, she stated that she knows that a lot of assessments are overdue to be transmitted and completed.
During an interview on December 9, 2021, at 2:45 PM, with the Director of Nurses (DON), DON stated that MDS has been a problem and that she is well aware that the facility is not in compliance with assessments being completed on time.
A facility's policy and procedure for timeframe for MDS assessment transmittal was requested. The facility did not provide a policy and procedure.
During a record review of the MDS manual titled CMS's RAI version 3.0 Manual, Chapter 5: Submission and Correction of the MDS Assessments, indicated, Completion Timing .for comprehensive MDS assessments, the completion date must be no later than 14 days after the assessment date.

Based on interviews, and record review, the facility failed to transmit Minimum Data Set (MDS) assessments (a federally mandated process for assessing resident's functional capabilities and health needs) following a significant change in status for 3 out of 22 sampled residents.
This had a potential to cause harm due to missed tracking and trending of changes and/or declines in a resident's condition.
Findings:
During a record review on December 8, 2021, at 9:10 AM, it was noted that there were three MDS assessments for a significant change that had not been transmitted and were still in progress for Resident 60, Resident 66 and Resident 229.
During an interview on December 8, 2021, at 10:00 AM, with the Administrator, he stated that the facility had been having trouble hiring and keeping an MDS coordinator and there hadn't been one for quite some time and he was aware that a lot of the MDS assessments had not been completed or transmitted.
During an interview on December 8, 2021, at 2:00 PM, with the MDS Consultant, she stated that she knows that a lot of assessments are overdue to be transmitted and completed.
During an interview on December 9, 2021, at 2:45 PM, with the DON, she stated that MDS has been a problem and that she is well aware that the facility is not in compliance with assessments being completed on time.
A facility's policy amd procedure for transmittal of the MDS assessment following a significant change was requested. The facility did not provide a policy and procedure.
During a record review of the MDS manual titled CMS's RAI version 3.0 Manual, Chapter 5: Submission and Correction of the MDS Assessments. Lists For Significant Change in Status Assessment .the completion date must be no later than 14 days from the assessment date and no later than 14 days from the determination date of a significant change in status.

Based on interviews, and record review, the facility failed to transmit quarterly Minimum Data Set (MDS) assessments (a federally mandated process for assessing resident's functional capabilities and health needs) within the required quarterly timeframe parameters for 20 out of 22 sampled residents.
This had a potential to cause harm due to missed tracking and trending of changes and/or declines in a resident's condition.
Findings:
During a record review on December 8, 2021, at 9:10 AM, it was noted that there were quarterly MDS assessments that had not been transmitted for Resident 29, Resident 60, Resident 9, Resident 28, Resident 7, Resident 14, Resident 61, Resident 13, Resident 25, Resident 8, Resident 3, Resident 53, Resident 15, Resident 26, Resident 12, Resident 54, Resident 6, Resident 30, Resident 27 and Resident 11.
During an interview on December 8, 2021, at 10:00 AM, with the Administrator (ADM), The ADM stated that the facility had been having trouble keeping an MDS coordinator and there hadn't been one for quite some time and he was aware that a lot of the MDS assessments had not been completed or transmitted.
During an interview on December 8, 2021, at 2:00 PM, with the MDS Consultant, she stated that she knows that a lot of assessments are overdue to be transmitted and completed.
During an interview on December 9, 2021, at 2:45 PM, with the Director of Nurses (DON), DON stated that MDS has been a problem and that she is well aware that the facility is not in compliance with assessments being completed on time.
A facility's policy and procedure for MDS quaterly assessment transmittal was requested. The facility did not provide a policy and procedure.
During a record review of the MDS manual titled CMS's RAI version 3.0 Manual, Chapter 5: Submission and Correction of the MDS Assessments, indicated .For all non-admission assessments, the MDS completion date must be no later than 14 days after the assessment date.

Based on interviews, and record review, the facility failed to ensure that a Registered Nurse (RN) was signing, and tracking completed Minimum Data Set (MDS) assessments (a federally mandated process for assessing resident's functional capabilities and health needs) for 20 out of 22 sampled residents.
This had the potential to cause harm due to missed tracking and trending of changes and/or declines in a resident's condition.
Findings:
During a record review on December 8, 2021, at 9:10 AM, it was noted that there were MDS assessments that had not been transmitted and were still in progress for Resident 29, Resident 60, Resident 9, Resident 28, Resident 7, Resident 14, Resident 61, Resident 13, Resident 25, Resident 8, Resident 3, Resident 53, Resident 15, Resident 26, Resident 12, Resident 54, Resident 6, Resident 30, Resident 27 and Resident 11.
During an interview on December 8, 2021, at 2:00 PM, with the MDS Consultant, she stated that the Director of Nurses (DON) is the RN responsible for signing and tracking the MDS Assessments.
During an interview on December 8, 2021, at 2:20 PM, with the DON, she stated that she is the RN who is responsible for signing the MDS assessments, she stated that she gets emails to inform her that the assessments are due to be signed but she doesn't have the time right now to get them done because she has so much other work to do.
A facility's policy and procedure for RN signing and tracking completed MDS was requested. The facility did not provide a policy and procedure.
During a record review of the MDS manual CMS's RAI Version 3.0 Manual. Outlined that Federal regulation requires the RN assessment coordinator to sign and thereby certify that the assessment is complete.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of 18 residents (Resident 10) received needed care and services when Physical Therapist ( PT ) did not follow physician orders for a physical therapy evaluation.
This failure had the potential to lead Resident 10 to further decline in physical functioning.
Finding:
During a review of Resident 10's face sheet (a facility document containing basic information about the resident) indicated, Resident 10 was admitted to the facility on [DATE], with diagnoses which included hydrocephalus (fluid build-up in the brain that can affect walking, balance and normal brain functioning), hypertension (high blood pressure), and weakness (decrease in body strength).
During an interview on December 6, 2021, at 3:52 PM, with Resident 10, in the resident's room, Resident 10 stated she requested for physical therapy but has not received it yet.
During a review of Resident 10's physician orders dated December 2, 2021, the physician orders indicated, PT Evaluation for Restorative Nurse Assistant (RNA- a staff member who assist residents with exercises).
During an interview on December 9, 2021, at 2:38 PM, with PT, PT stated she was not aware of Resident 10's order for PT Evaluation for RNA. PT further stated Resident 10 order was not on her list, and she does not know how to check for new physical therapy orders.
During an interview on December 9, 2021, at 3:30 PM, with Licensed Vocational Nurse (LVN 1) stated new physician orders can be viewed by staff in the daily communications log in the Electronic Medical Record (EMR). LVN 1stated she communicates new orders for physical therapy to the PT by printing a copy of the order and giving it to the PT. LVN 1 further stated if the PT is not available, she will place a copy of the order under the door to the physical therapy room.
During an interview on December 9, 2021, at 3:35 PM, with LVN 2 stated staff can check for new orders in the EMR under Communications. LVN 2 stated she will print a copy of the order and give it to the PT.
During an interview on December 9, 2021, at 4:00 PM, with Registered Nurse (RN 1), RN 1 stated the normal process for communicating new orders for physical therapy is to enter the order in the computer, print a copy of the order, and give it to the PT.
During a follow up interview on December 9, 2021, at 4:15 PM, with the PT, PT stated she does not have any copies of PT orders from the nurses. PT stated she sometimes gets papers from under the door that look like they are for nurses so she discards them.
During a review of the facility's policy and procedure titled, Policy and Procedure Therapy Services, undated, under the section, Policy Explanation and Compliance Guidelines for Evaluation, indicated, 1 The Rehabilitation Department will be notified when a physician order is written for therapy evaluation and treatment. 2. The Licensed Therapist will perform a chart review and initiate the evaluation .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure Resident 42 did not develop a reoccurrence of a pressure ulcer (a skin injury caused by pressure) to the right and left heels when facility was not following Resident 42's care plan of applying heel protectors.
This failure resulted in Resident 42 developing a reoccurrence of a pressure ulcer to the right and left heels.
Finding:
During a review of Resident 42 face sheet (a document which contains basic information about the resident) indicated Resident 42 was admitted to the facility on [DATE], with diagnoses which included dementia (a disease of the brain which causes memory loss), transient ischemic attack (a mini stroke), and convulsions (a disease of the brain which causes uncontrollable shaking).
During an observation on December 6, 2021 at 2:30 PM, Resident 42 was in lying in bed. Resident 42 had a small dark color wound to the right and left heels. Further observation, Resident 42 did not have right and left heel protectors on her heels.
During an interview with Registered Nurse (RN 2) on December 6, 2021 at 2:40 PM, the RN 2 confirmed Resident 42 did not have right and left heel protectors in place and developed a reoccurrence of a small dark colored wound to the right and left heels. RN 2 stated, The resident should have heel protectors. The RN 2 further stated The resident should not have wounds to the heels if the heel protectors are applied.
During an interview with Certified Nursing Assistant (CNA 3) assigned to Resident 42 on December 6, 2021 at 2:50 PM, CNA 3 confirmed Resident 42 did not have the heel protectors on and developed a small dark color wound to the right and left heels. CNA 3 stated, I will apply the heel protectors right now. The CNA 1 further stated, The resident should not have wounds to the heel.
During a review of Resident 42 wound report, dated December 8, 2021, documented unstageable Right Heel pressure measuring 0.7 centimeters (cm-a unit of measurement) by 0.8 cm, and unstageable left heel pressure measuring 1.0 cm by 1.0 cm.
During a review of Resident 42's nursing care plan, one of the interventions included, Heel protectors.
During a review of the facility's policy and procedure titled, Prevention of Pressure Ulcers/Injuries Revised July 2017, indicated, Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure Resident 42 physician's order were followed when
1. Right and left heel protectors (a device used to prevent skin breakdown) were not applied as ordered by the physician.
2. Left carrot hand splints (a device used to prevent contractures from getting worse) was not applied as ordered by the physician.
These failures had the potential to jeopardize Resident 42 health and safety.
Findings:
1. During an observation on December 6, 2021 at 2:30 PM, Resident 42 was in laying in bed. Resident 42 right and left heel did not have heel protectors.
A review of Resident 42's physician orders, dated March 10, 2021, indicated, Heel Protectors while in bed for skin maintenance every shift.
During an interview with Registered Nurse (RN 2) on December 6, 2021 at 2:40 PM, the RN 2 confirmed the right and left heel did not have heel protectors. RN 1 stated, The right and left heel should have heel protectors. The RNA usually applies the heel protectors. The RNA called off today.
During an interview with Certified Nursing Assistant (CNA 3) assigned to Resident 42 on December 6, 2021 at 2:50 PM, CNA 3 confirmed the right and left heels did not have heel protectors. CNA 3 stated, The RNA applies the heel protectors. He called off. I will apply them right now.
2. During an observation on December 6, 2021 at 2:35 PM, Resident 42 was lying in bed. Resident 42 did not have a left hands carrot splint.
A review of Resident 42's physician orders, dated October 5, 2021, indicated, RNA to apply carrot to left hand one time a day for skin check.
During an interview with Registered Nurse (RN 2) on December 6, 2021 at 2:40 PM, the RN 2 confirmed Resident 42 did not have left hand carrot splint. RN 2 stated, The resident should have a left carrot hand splint. The RNA usually applies the left carrot hand splint.
During an interview with Certified Nursing Assistant (CNA 3) assigned to Resident 42 on December 6, 2021 at 2:50 PM, CNA 3 confirmed Resident 42 did not have left carrot hand splint on. The CNA 3 stated, The RNA applies the left carrot hand. The RNA called off today. I will apply the left carrot hand splint.
During a review of Resident 42's face sheet (a basic document which contains basic information about the resident) indicated Resident 42 was admitted to the facility on [DATE], with diagnoses which included dementia (a disease of the brain which causes memory loss), transient ischemic attack (a mini stroke), and convulsions (a disease of the brain which causes uncontrollable shaking).
During a review of the facility's policy and procedure titled, Restorative Nursing Program dated November 30, 2020, indicated, c. Assisting residents to adjust to their disabilities, to use their orthotic devices such as hand rolls, splints, AFOs, and braces, and to redirect their interests, if necessary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide sufficient staffing to assure resident safety and the well-being of residents when:
1. A resident (Resident 279) did not receive a PRN (as needed) respiratory treatment in a timely manner.
2. A resident (Resident 17) had to eat in his room instead of the dining room due to not enough staff available to supervise the dining room during mealtimes.
3. A shortage of hours was noted on the Census and Direct Care Service Hours Per Patient Day (DHPPD) on five of six days (December 2, 3, 4, 5, and 6, 2021) reviewed.
This failure had the potential to negatively affect the health and safety of medically compromised residents in the facility.
Finding:
1. During a review of Resident 279's Face sheet (a facility document with basic information about the resident), the document indicated, Resident 279 was admitted on [DATE], with diagnoses which included chronic obstructive pulmonary disease (block in airflow through the lungs that causes breathing-related problems) with acute exacerbation (sudden worsening in breathing such as increased shortness of breath) and anxiety disorder (mental condition causing excessive fear or worry in non-threatening situations).
During a concurrent observation and interview on December 6, 2021, at 11:30 AM, with Resident 279, in the resident's room, Resident 279 was noted to be wearing a nasal cannula (a tube that delivers oxygen through the nose). Resident 279 stated she receives her breathing treatments late; usually an hour or longer before she gets the treatment. Resident 279 further stated on Friday, December 3, 2021, she requested a PRN breathing treatment at 7 AM and did not receive her breathing treatment until 9 AM. Resident 279, stated the facility is short of staff.
During a review of Resident 279's Medication Administration Record (MAR), dated December 3, 2021, the MAR indicated, Resident 279 received a PRN breathing treatment on December 3, 2021 at 3:13 AM by the night shift nurse. Resident 279 was due for another PRN breathing treatment by 7:13 AM.
A review of Resident 279's MAR indicated, Resident 279 did not receive a PRN breathing treatment until December 3, 2021 at 9:05 AM by the day shift nurse, three hours after Resident 279 requested the PRN breathing treatment.
A review of Resident 279's physician orders, dated November 23, 2021, indicated, Albuterol Sulfate ( medication given to make breathing easier) Nebulization (a machine that is use to administer the medication) Solution (2.5 MG/3ML) (milligrams per milliliter - unit of measurement) 0.083% (the strength of the medication) 3 ml (milliliters - unit of measurement) inhale orally via nebulizer (small machine turns liquid medication into a mist that is breathed in through a mouthpiece) every 4 hours as needed for Shortness of Breath Rinse mouth after use.
During a concurrent interview and record review on December 10, 2021, at 10:10 AM, with Licensed Vocational Nurse (LVN 2), LVN 2 stated a PRN respiratory treatment should be given as soon as possible after requested by a resident.
2. During a review of Resident 17's face sheet (a facility document which contains basic information about the resident), the document indicated, Resident 17 was admitted on [DATE], with diagnoses which included convulsions (uncontrolled shaking of the body) and hematuria (blood in the urine).
During an interview on December 7, 2021, at 9:36 AM, with Resident 17, in the resident's room, Resident 17 stated, there is not enough staff on the weekends. Resident 17 stated the staff make him eat in his room when there is not enough staff to supervise the dining room.
During an interview on December 9, 2021, at 11:30 AM, with Certified Nurse Assistant (CNA 1), CNA 1 stated she works Saturdays, night shift. When asked if the resident dining room is ever closed, CNA 1 stated they sometimes close the dining room during dinner time if they are short-staffed.
A review of the facility's Census and Direct Care Service Hours Per Patient Day (DHPPD) (DHPPD), dated Saturday, December 4, 2021, indicated, the facility had an actual DHPPD of 2.52 hours (below the state's 3.5 hour minimum). The DHPPD further indicated, the facility had an actual CNA DHPPD of 1.74 hours (below the state's 2.4 minimum).
A review of the facility's Census and Direct Care Service Hours Per Patient Day (DHPPD) (DHPPD), dated Sunday, December 5, 2021, indicated, the facility had an actual DHPPD of 3.13 hours (below the state's 3.5 hour minimum). The DHPPD further indicated, the facility had an actual CNA DHPPD of 2.28 hours (below the state's 2.4 minimum).
During an interview with the administrator (ADM) on December 10, 2021 at 9:30 AM, ADM confirmed DHPPD of 2.52 hours (below the state's 3.5 minimum hours) on Saturday, December 4, 2021 and DHPPD of 3.13 hours (below the state's 3.5 minimum hours) on Sunday, December 5, 2021. The ADM stated staffing the facility is a challenge.
3. During an interview on December 8, 2021, at 5:47 AM, with CNA 2, CNA 2 stated they are short staffed, sometimes only having one CNA for two hallways (facility has four hallways of rooms - 100s, 200s, 300s, and 400s rooms). CNA 2 stated this happens often.
During an interview on December 7, 2021, at 4:30 PM, with Resident 32, in the resident's room, resident stated, the facility is on and off short-staffed, especially on night shift. Resident 32 stated sometimes there is one CNA for two hallways during the night shift.
During an interview on December 7, 2021 at 4:40 PM, with Resident 57, in the resident's room, resident stated the facility is on and off short-staffed, especially on night shift. Resident 57 stated sometimes there is one CNA for two hallways during the night shift.
During an interview on December 10, 2021, at 9:27 AM, with the Administrator (ADM), the ADM stated he is aware the facility is not meeting the required hours for staffing.
A review of the facility's Census and Direct Care Service Hours Per Patient Day (DHPPD) (DHPPD), dated Thursday, December 2, 2021, indicated, the facility had an actual DHPPD of 2.61 hours (below the state's 3.5 hour minimum). The DHPPD further indicated, the facility had an actual CNA DHPPD of 1.62 hours (below the state's 2.4 minimum).
A review of the facility's Census and Direct Care Service Hours Per Patient Day (DHPPD) (DHPPD), dated Friday, December 3, 2021, indicated, the facility had an actual DHPPD of 2.54 hours (below the state's 3.5 hour minimum). The DHPPD further indicated, the facility had an actual CNA DHPPD of 1.60 hours (below the state's 2.4 minimum).
A review of the facility's Census and Direct Care Service Hours Per Patient Day (DHPPD) (DHPPD), dated Saturday, December 4, 2021, indicated, the facility had an actual DHPPD of 2.52 hours (below the state's 3.5 hour minimum). The DHPPD further indicated, the facility had an actual CNA DHPPD of 1.74 hours (below the state's 2.4 minimum).
A review of the facility's Census and Direct Care Service Hours Per Patient Day (DHPPD) (DHPPD), dated Sunday, December 5, 2021, indicated, the facility had an actual DHPPD of 3.13 hours (below the state's 3.5 hour minimum). The DHPPD further indicated, the facility had an actual CNA DHPPD of 2.28 hours (below the state's 2.4 minimum).
A review of the facility's Census and Direct Care Service Hours Per Patient Day (DHPPD) (DHPPD), dated Monday, December 6, 2021, indicated, the facility had an actual DHPPD of 2.79 hours (below the state's 3.5 hour minimum). The DHPPD further indicated, the facility had an actual CNA DHPPD of 1.91 hours (below the state's 2.4 minimum).
During a review of the facility's policy and procedure titled, staffing, Revised October 2017, indicated, Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment.

Based on observation, interview, and record review the facility failed to ensure that medication was available for administration to a resident (Resident 71) when her 6:00 AM dose of Levothyroxine (Thyroid medication) was not found in the medication cart.
This had the potential to cause harmful symptoms such as weight gain, depression, muscle cramps, weakness and memory problems due to low thyroid levels
Findings:
During an observation and concurrent interview on October 8, 2021 at 5:48 AM, with a Licensed Vocational Nurse (LVN), she is observed administering medication for Resident 71. Levothyroxine 125mcg was missing from the medication cart and was not available to administer. The LVN stated that the medication is not available in the e-kit, (a kit containing medication that can be given in an emergency when it is not available in the medication cart) so she will leave a message for the Doctor to let them know it wasn't given.
During a record review of Resident 330's medication administration record, there is an active order for Levothyroxine Sodium Tablet 125 MCG, Give 1 tablet by mouth one time a day at 6:30 AM, for low thyroid hormone. With a start date of October 20, 2021.
During an interview on December 8, 2021 at 7:30 AM, with Resident 330, she stated that the nurse didn't give me the thyroid medicine that I take every day because she didn't have any to give me. She stated that I need that medication because I doesn't have a thyroid anymore.
During an observation on December 8, 2021 at 1:35 PM the medication e-kit is noted to not contain any Levothyroxine medication.
During an interview on December 8, 2021, at 10:25 AM, with RN1, she stated that when medication is not available the nurse should call the doctor to let them know and also contact pharmacy to send a refill.
During an interview with the pharmacy tech, she states that no-one has called to request a refill of Resident 71's Levothyroxine, she stated that they sent a 14-day supply on November 15, 2021, but no-one has called to request a refill since then.
During an interview and concurrent observation with the DON she showed that there is a colored strip on the medication blister packs which alerts staff that they should call pharmacy for a refill. She stated that staff should call the pharmacy for more medication before the medication runs out.
During a record review of the facility policy and procedure titled, Administering Medications with a revision date of December 2012, lists, .3. Medications must be administered in accordance with the orders, including any required timeframe.

Based on observation, interview, and record review the facility failed to ensure that medication was disposed of per facility policy when a bottle of medication and a blister pack of pills was found in the medication disposal container in the med room.
This had the potential to cause harm due to medication being able to be removed from the waste container and misappropriated.
Findings:
During an observation and concurrent interview on December 8, 2021, at 1:20 PM, with a Licensed Vocational Nurse (LVN 2), in the medication room, a medication disposal container was seen to have a bottle of medication and a blister pack with full pills inside. LVN 2 stated that medication should be emptied out of bottles, and pills should be removed from blister packs before being disposed of in the medication waste container.
During an interview on December 8, 2021, at 1:25 PM, with the Director of Nursing (DON), she stated that medication should never be left in the original containers when they are being disposed of in the medication disposal container. She stated that pills should be emptied out of the blister packs and liquid medication should be poured into the container and emptied out of the bottle.
During a record review of the facility policy and procedure titled, Discarding and Destroying Medications with a revision date of October 2014, notes .a. Take medication out of the original containers.

Based on observation, interview and record review, the facility failed to store food in accordance with professional standards for food service safety when:
1. Temperature logs were not updated for four shifts for the refrigerator and freezer.
This failure had the potential to cause foodborne illnesses in a medically vulnerable resident population in the universe of 70 out of 72 who consumed food prepared in the kitchen.
Findings:
Review of the facility resident Diet List dated December 6, 2021, a total of 70 Residents out of 72 residents in the facility received food prepared in the kitchen.
During an observation on December 6, 2021 at 11:30 AM, temperature logs for the walk-in refrigerator and walk-in freezer were not filled out for the PM shift of December 1, 2021, the AM shift of December 2, 2021, the AM shift of December 3, 2021.
During an observation on December 9, 2021 at 9:30 AM, the temperature logs for the walk-in refrigerator and walk-in freezer were not filled out for the PM shift of December 7, 2021.
During an interview on December 9, 2021 at 9:35 AM, the Dietary Supervisor (DS) states that staff should be documenting the refrigerator and freezer temperatures every morning at the start of shift and every evening at the end of shift.
According the facility policy, Refrigerators and Freezers revised December 2014. Food Service Supervisors or designated employees will check and record refrigerator and freezer temperatures daily with first opening and at closing in the evening.

Based on interview, and record review the facility failed to implement an antibiotic stewardship program (an effort to measure and improve how antibiotics are prescribed by physicians and used by patients) when Resident 330 was prescribed antibiotics and there were no criteria used to ensure that they had been prescribed appropriately.
This failure had a potential to ineffectively treat infections, protect patients from harm caused by unnecessary antibiotic use and combat antibiotic resistance.
Findings:
During an interview with Licensed Vocational Nurse (LVN 1), she stated that the physician orders antibiotics, but she doesn't know about an antibiotic stewardship program.
During an interview and concurrent record review with the Director of Nurses (DON), she stated that they have an antibiotic stewardship program which includes ensuring that residents are prescribed antibiotics appropriately using the McGeers criteria. A review of the antibiotic stewardship binder shows no entries of antibiotic use for 2021.
During an interview and concurrent record review with the DON of Resident 330's electronic medical record, she stated that the resident was prescribed the antibiotic Levaquin 500mg for a suspected urinary tract infection. She stated that antibiotic use should have been assessed using an Infection Control Surveillance tool, but it had not been initiated or completed.
During a record review of the facility policy titled, Antibiotic Stewardship with a revision date of December 2016, the policy Statement includes, Antibiotics will be prescribed and administered to residents under the guidance of the facility's Antibiotic Stewardship Program.

Based on interviews, and record review, the facility failed to transmit Minimum Data Set (MDS) assessments (a federally mandated process for assessing resident's functional capabilities and health needs) within the required timeframes for 20 out of 22 sampled residents.
This had a potential to cause harm due to missed tracking and trending of changes and/or declines in a resident's condition.
Findings:
During a record review on December 8, 2021, at 9:10 AM, it was noted that there were MDS assessments that had not been transmitted and were still in progress for Resident 29, Resident 60, Resident 9, Resident 28, Resident 7, Resident 14, Resident 61, Resident 13, Resident 25, Resident 8, Resident 3, Resident 53, Resident 15, Resident 26, Resident 12, Resident 54, Resident 6, Resident 30, Resident 27 and Resident 11.
During an interview on December 8, 2021, at 10:00 AM, with the Administrator, he stated that the facility had been having trouble keeping an MDS coordinator and there hadn't been one for quite some time and he was aware that a lot of the MDS assessments had not been completed or transmitted.
During an interview on December 8, 2021, at 2:00 PM, with the MDS Consultant, she stated that she knows that a lot of assessments are overdue to be transmitted and completed.
During an interview on December 9, 2021, at 2:45 PM, with the DON, she stated that MDS has been a problem and that she is well aware that the facility is not in compliance with assessments being completed on time.
A facility's policy and procedure for transmittal of the MDS assessment within the required timeframes was requested. The facility did not provide a policy and procedure.
During a record review of the MDS manual titled CMS's RAI version 3.0 Manual, Chapter 5: Submission and Correction of the MDS Assessments. Noted, ' .For all non-admission assessments, the MDS Completion Date must be no later than 14 days after the assessment date .For the admission assessment, the MDS Completion Date must be no later than 13 days after the Entry Date .For the other comprehensive MDS assessments, Significant Change in Status Assessment and Significant Correction to Prior Comprehensive Assessment, the completion date must be no later than 14 days from the assessment date and no later than 14 days from the determination date of the significant change in status or the significant error, respectively. For Entry and Death in Facility tracking records, the MDS Completion Date must be no later than 7 days from the Event Date.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure Resident 42's right and left hand fingernails were clean and trimmed.
This failure has the potential for Resident 42 to experience skin tears and infections.
Finding:
During a review of Resident 42 face sheet (a basic document which contains basic information about the resident) indicated Resident 42 was admitted to the facility on [DATE], with diagnoses which included dementia (a disease of the brain which causes memory loss), transient ischemic attack (a mini stroke), and convulsions (a disease of the brain which causes uncontrollable shaking).
During an observation on December 6, 2021 at 3 PM, Resident 42 was in lying in bed. Resident 42's right and left hands fingernails were long and had dark colored matter underneath the fingernail.
During an interview with Registered Nurse (RN 2) on December 6, 2021 at 3:20 PM, RN 2 confirmed the right and left hands fingernails were long and had dark color matter underneath the fingernails. RN 1 stated, The nails should be clean and trimmed.
During an interview with Certified Nursing Assistant (CNA 3) assigned to Resident 42 on December 6, 2021 at 3:40 PM, CNA 3 confirmed the right and left hand fingernails were long and had dark color matter underneath the fingernails. CNA 3 stated, I will clean and cut the fingernails.
During a review of the facility's policy and procedure titled, Care of Fingernails/Toenails, Revised February 2018, indicated under General Guidelines. 1. Nail care includes daily cleaning and regular trimming.