SUNDANCE SKILLED NURSING AND REHABILITATION

INITIAL COMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility's general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.90(a). The facility is two story, Type V (111), construction. The facility is protected throughout by National Fire Protection Association (NFPA) 13 automatic fire suppression systems and is classified as Fully Sprinklered. The facility was constructed in the early 1900's to 1973 and is licensed for 68 beds. This re-certification survey was conducted on March 26, 2026, for compliance with the National Fire Protection Association (NFPA 101) Life Safety Code (2012) "Chapter 19, Existing Health Care Occupancies". The deficiencies cited were discussed with the Director of Plant Operations during the survey any again during the exit conference.

Based on records review, observation, and staff interview, the facility failed to provide life safety drawings in accordance with the requirements of Life Safety Code NFPA 101 (2012), and referenced standards. These are needed to verify maintenance of associated fire barriers to maintain defined in place concepts. Findings Include:Facility did not have or provide schematic life safety drawings at time of survey. Regulatory References: NFPA 1014.2 Objectives. 4.2.1 Occupant Protection. A structure shall be designed, constructed, and maintained to protect occupants who are not intimate with the initial fire development for the time needed to evacuate, relocate, or defend in place. 4.2.2 Structural Integrity. Structural integrity shall be maintained for the time needed to evacuate, relocate, or defend in place occupants who are not intimate with the initial fire development. 4.2.3 Systems Effectiveness. Systems utilized to achieve the goals of Section 4.1 shall be effective in mitigating the hazard or condition for which they are being used, shall be reliable, shall be maintained to the level at which they were designed to operate, and shall remain operational. NFPA 101 (2012), §5.8.1 5.8 Documentation Requirements. 5.8.1General. - All aspects of the design, including those described in 5.8.2 through 5.8.14, shall be documented. The format and content of the documentation shall be acceptable to the authority having jurisdiction. Enhanced ContentThe maintenance of proper documentation plays an important role in at least three phases of the building life cycle. The documentation needs to be used by the AHJ and other design team members during the design acceptance, construction, and approval that lead to a certificate of occupancy. The documentation needs to be used whenever any potential rehabilitation or change in use is considered. The documentation needs to be used in preparation of the yearly warrant of fitness that certifies compliance with the conditions and limitations of the performance-based design as required by 4.6.9.2This deficiency has the potential to affect all residents within the facility. The deficiency was discussed with the facility director and the regional director of plant operations during the survey exit conference.

Based on observation and interview, it was determined that the facility failed to maintain the kitchen hood suppression system as required by NFPA 96. 1. Cooking equipment with casters needs wheel chalks NFPA 96 13.1.2.3 ([2011] 12.1.2.3) The fire-extinguishing system shall not require re-evaluation where the cooking appliances are moved for the purposes of maintenance and cleaning, provided the appliances are returned to approved design location prior to cooking operations, and any disconnected fire-extinguishing system nozzles attached to the appliances are reconnected in accordance with the manufacturer’s listed design manual. 13.1.2.3.1* ([2011] 12.1.2.3.1)An approved method shall be provided that will ensure that the appliance is returned to an approved design location. This deficiency has the potential to affect approximately 10 residents within the facility. Deficient items were discussed with the administrator and maintenance director at the exit conference.

Based on observations and records review, it was determined that the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association NFPA 25 and NFPA 101 Sprinkler heads presented during survey are dated 1973 | Heads are due for sample testing or replacement NFPA 101: 4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or other feature shall thereafter be continuously maintained. Maintenance shall be provided in accordance with applicable NFPA requirements or requirements developed as part of a performance-based design, or as directed by the authority having jurisdiction. NFPA 25 5.3.1.1.1 Where sprinklers have been in service for 50 years, they shall be replaced or representative samples from one or more sample areas shall be tested. This deficiency has the potential to affect all residents within the facility. Deficient items were discussed with the administrator and maintenance director at the exit conference.

Based on observations and records review, it was determined that the facility failed to use room separation curtains in accordance with NFPA 101 (12) 1. Room curtains did not appear to be NFPA compliant (No NFPA tag present) 19.7.5.1* Draperies, curtains, and other loosely hanging fabrics and films serving as furnishings or decorations in health care occupancies shall be in accordance with the provisions of 10.3.1(see 19.3.5.11), and the following also shall apply:(1)Such curtains shall include cubicle curtains.(2)Such curtains shall not include curtains at showers and baths.(3)Such draperies and curtains shall not include draperies and curtains at windows in patient sleeping rooms in smoke compartments sprinklered in accordance with 19.3.5.(4)Such draperies and curtains shall not include draperies and curtains in other rooms or areas where the draperies and curtains comply with all of the following:(a)Individual drapery or curtain panel area does not exceed 48 ft2 (4.5 m2).(b)Total area of drapery and curtain panels per room or area does not exceed 20 percent of the aggregate area of the wall on which they are located.(c)Smoke compartment in which draperies or curtains are located is sprinklered in accordance with 19.3.5. NFPA 101 — Life Safety Code (2012)10.3.1 * Where required by the applicable provisions of this Code, draperies, curtains, and other similar loosely hanging furnishings and decorations shall meet the flame propagation performance criteria contained in NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films. This deficiency has the potential to affect approximately 40 residents within the facility. Deficient items were discussed with the administrator and maintenance director at the exit conference.

A recertification survey with complaint #CO2730147, #CO2747006, Incident #2740609, Incident #2740616, Incident #2740625 and Incident #2740629 was conducted on 2/23/26 to 2/26/26. Seventeen deficiencies were cited.

An Emergency Preparedness survey was conducted from 2/23/26 to 2/26/26. No deficiencies were cited.

Based on record review and interviews, the facility failed to ensure one (#69) of two residents reviewed for personal property out of 41 sample residents was able to retain their personal belongings. Specifically, the facility failed to receive consent from Resident #69 or his responsible party before disposing of his personal belongings after the resident was discharged to the hospital. Findings include:I. Resident #69A. Resident statusResident #69, age less than 65, was admitted on 10/5/18. According to the February 2026 computerized physician orders (CPO), diagnoses included quadriplegia and systemic lupus. The 12/5/25 minimum data set (MDS) assessment documented the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. B. Record reviewA nursing note, dated 12/6/25, revealed Resident #69’s physician assessed him and found that the resident had phimosis (a condition where the foreskin could not be retracted) which required medical intervention. The physician ordered that the resident be transferred to the hospital. A social services note, dated 12/17/25, revealed the social services director (SSD) had a phone meeting with the resident's representative about his condition and discussed whether readmission would be plausible. The resident was going to start dialysis. A social services note, dated 2/11/26, revealed the SSD contacted the resident's representative regarding finding Resident #69’s missing electronic tablet in the facility’s lost and found. The representative asked if the resident's items were still in his room and the SSD informed the sister that his room had been cleaned out. The SSD said she would reach out to the director of nursing (DON) to find out if the items had been stored by someone, as the SSD was not aware of any discussions that might have happened between the family and other management. The SSD spoke with the admission director who said she had left Resident #69’s representative a voicemail on 1/5/26 letting her know that since the resident had not been readmitted to the facility, his items would be packed up and stored. The admissions director told the SSD that the items had been packed up on 1/10/26 and stored in the facility’s basement. The SSD spoke with the maintenance director who said that the items had been disposed of on 2/2/26 after storing the items for over the 30-day period (57 days). The SSD contacted both the resident's representatives on 2/11/26 and advised them of the disposal of many of the resident's personal items. The representatives were upset when provided with this information. A social services note, dated 2/11/26, revealed that the SSD called the resident's representatives back and let them know that his electric wheelchair, electronic tablet, and television had been found. When the SSD tried to discuss arrangements to pick up the items, the family discontinued the call. A social services note, dated 2/12/26, revealed the SSD spoke with the resident’s representative and told her that she had 14 days to pick up his remaining items. The representative said she would pick up his belongings. -Review of Resident #69’s electronic medical record (EMR) between 12/17/25 and 2/11/26 revealed there were no progress notes indicating the resident’s representatives were notified to come and pick up the resident’s belongings.-Review of the resident’s EMR revealed there were no progress notes documented to indicate an initial call was made by the admissions director to the resident’s representatives advising them of the potential that the resident's items would be disposed of in 30 days. II. Staff interviewsSSD #1 was interviewed on 2/25/26 at 1:00 p.m. SSD #1 said she had been the one to have a phone conference with Resident #69’s representatives in December 2025 regarding the resident returning to the facility from the hospital. She said, at that time, she thought he was going to be readmitted to the facility, so there was not a conversation regarding storing his personal belongings. SSD #2 was interviewed on 2/25/26 at 1:18 p.m. SSD #2 said she had made the follow-up calls to Resident #69’s representatives in February 2026. She said the admissions director did not usually make progress notes when she called families. SSD #2 said the facility would notify the families that items would be stored for 30 days and then disposed, of but the notification to Resident #69’s representatives was a verbal notification. III. Facility follow-upOn 2/25/26 at approximately 3:00 p.m., SSD #2 provided an addendum to the facility’s policy on discharge to include residents’ personal items left in the facility. The policy outlined that all personal items would be packed, labeled, inventoried, and stored by the facility in a secure area of the basement. The social services department would make the verbal notification to the family and document a progress note. After 14 days, the social services department would send a reminder letter with the specific timeframe for pick up of residents’ belongings. After the 30 days timeframe expired, the social services department would call the family to remind them about picking up the belongings and inquire about when items would be picked up. If the family wanted items to be disposed of or donated, a written letter would document this and the family would sign it.

Based on record review and interviews, the facility failed to consider resident and family group views and act upon grievances and recommendations. Specifically, the facility failed to provide the residents the opportunity to share views, grievances, and recommendations to dietary related issues in the resident council meetings. Findings include:I. Facility policy and procedureThe Grievance policy, undated, was provided by the nursing home administrator (NHA) on 2/26/26 at 4:53 p.m. It read in pertinent part, "All grievances, complaints, or recommendations stemming from resident or family groups will be considered. Actions on such items will be responded to in writing, including a rationale for the response."II. Resident group interviewFive alert and oriented residents (#24, #2, #7, #56 and #58) who regularly attended the resident council meetings and were deemed interviewable by assessment and the facility were interviewed together on 2/25/26 at 10:30 a.m. The residents were identified as alert and oriented through facility and assessment. The group of residents said the facility did not include dietary concerns in the resident council meetings and instead had a separate food committee meeting, but it had been several months since the facility had provided the residents with the opportunity to have a food committee meeting. Resident #24 said the dietary concerns brought up in the resident council meetings were redirected to the food committee meeting. He said any food concerns brought up in the resident council meeting were not addressed by staff. III. Record reviewA review of the resident council meeting minutes, dated December 2025, revealed the resident council meeting was cancelled due to a COVID-19 outbreak in the facility. A review of the resident council meeting minutes, dated 1/7/26, revealed all concerns regarding dietary were deferred to the food committee. A review of the resident council meeting minutes, dated 2/11/26, revealed all concerns regarding dietary were deferred to the food committee on 2/17/26.-However, the facility was unable to provide documentation that a food committee meeting took place on 2/17/26. A review of the food committee meeting notes revealed the food committee meeting had not been conducted since 10/25/25. IV. Staff interviewsSocial services director (SSD) #2 was interviewed on 2/26/26 at 1:01p.m. SSD #2 said she facilitated the resident council meetings and the facility had a process for addressing grievances identified in the resident council. SSD #2 said that dietary issues brought up in the resident council meetings were redirected to the food committee and the food committee meeting was run by the dietary manager. She said that the facility did not currently have a dietary manager and SSD #2 was not sure when the facility last had a food committee meeting. She said concerns brought up in the food committee meetings would be taken to the grievance official, the NHA. The NHA was interviewed on 2/26/25 at 2:35 p.m. The NHA said that the facility had not had a dietary manager since the previous week (the week of 2/16/26) and prior to that, the dietary manager was sporadically running the food committee meetings. The NHA said any food concerns brought up in the food committee meeting should be handled the same way as concerns brought up in resident council meetings, with a written concern form. She said she did not have any food committee meeting minutes from November 2025, December 2025, January 2026 or February 2026 and she could not say if the dietary manager was holding the food committee meetings during those months.

Based on observations, record review, and interviews, the facility failed to ensure that clean linens were provided to residents on a daily basis. Specifically, the facility failed to ensure clean hand towels and washcloths were provided to residents. Findings include:I. ObservationsObservations made throughout the survey (from 2/23/26 to 2/26/26) revealed there were no towel racks inside the residents’ bathrooms. On 2/23/26 at 3:38 p.m. room #224 B had no hand towels or washcloths. On 2/23/26 at 5:43 p.m. room #222 A and B had no hand towels or washclothsOn 2/25/26 beginning at 2:27 p.m., the following observations were made:-Room #102 had no hand towels or washcloths;-Room #103 had no hand towels or washcloths;-Room #104 had no hand towels or washcloths;-Room #117 had no hand towels or washcloths;-Room #222 had no hand towels or washcloths;-Room #223 had no hand towels or washcloths;-Room #224 had no hand towels or washcloths;-Room #227 had no hand towels or washcloths;-Room #232 had no hand towels or washcloths;-Room #235 had no hand towels or washcloths;-Room #234 had no hand towels or washcloths; and,-Room #230 had no hand towels or washcloths. On 2/26/26 at 9:24 a.m. the linen closet on the first floor was observed with certified nurse aide (CNA) #7. The linen closet contained 20 washcloths and 15 hand towels. On 2/26/26 at 9:28 a.m. the linen closet on the second floor was observed with licensed practical nurse (LPN) #1. The linen closet was locked with a combination padlock. There were approximately 15 washcloths and hand towels inside the linen closet. On 2/26/26 at 3:04 p.m. the closets of room #223 bed A and bed B and room #222 bed A and bed B did not have towel racks in the closets. Room #117 A and B both had a broken towel rack in the closet. II. Resident interviewsResident #55 was interviewed on 2/23/26 at 4:27 p.m. Resident #55 said that linen towels were not passed out. She said that at times, the facility had run out of bath towels. She said the bathroom had paper towels, but she said she did not like to use paper towels for her face. Resident #67 was interviewed on 2/23/26 at 5:30 p.m. Resident #67 said she was newly admitted to the facility and that she did not have any cloth linens in her room. She said the bathroom had only paper towels to dry her hands. Resident #52 was interviewed on 2/23/26 at 5:45 p.m. Resident #52 said the bathroom only had paper towels. She said that she did not get linen towels unless she asked for them. Resident #53 was interviewed on 2/25/26 at 2:35 p.m. Resident #53 said she did not have linen towels. She said that she had to use paper towels. The resident’s son was present in the room and confirmed that Resident #53 did not have linen towels in her room or the bathroom. Resident #60 was interviewed on 2/25/26 at 2:45 p.m. Resident #60 said there were no towels provided. She said that the bathroom only had paper towels. She said that she had to ask for a linen towel and then she kept the towel on her bed, as there was no other place to put the towel. Resident #56 was interviewed on 2/25/26 at 2:47 p.m. Resident #56 said there were no towels provided. She said once she received a towel, she would hold onto it. Resident #60 was interviewed a second time on 2/26/26 at 3:05 p.m. Resident #60 said there were not towel racks in the closet. Resident #67 was interviewed a second time on 2/26/26 at 3:10 p.m. Resident #67 said there were no towel racks in the closet. III. Resident group interviewFive residents (#2, #7, #24, #56 and #58) who were identified by the facility and assessment as interviewable, were interviewed together as a group on 2/25/26 at 10:00 a.m. The residents said they only had paper towels for drying their hands in their bathrooms. They said they had to ask for linen towels, but the staff did not go around and pass out towels. IV. Staff interviewsCertified nurse aide (CNA) #7 was interviewed on 2/26/26 at 9:24 a.m. CNA #7 said the linens were kept locked up in the linen closets. He said that the towels were locked up because residents would take too many towels. He said that if the residents asked, then the staff would give a hand towel and a washcloth to the resident. He said that the facility was low on towels. Certified nurse aide (CNA) #6 was interviewed on 2/26/26 at 9:32 a.m. CNA #6 said the residents had to ask for towels. He said there was a cart with towels, however, the residents were not allowed to get the towels themselves. Licensed practical nurse (LPN) #1 was interviewed on 2/26/26 at 9:30 a.m. LPN #1 said the towels were locked up on the second floor. She said the residents had to ask for towels, as they were not passed out. The director of nursing (DON) and the assistant director of nursing (ADON) were interviewed together on 2/26/26 at 2:30 p.m. The DON said the residents’ towels racks were in their closets. She said the towels were replaced as used on a daily basis.-However, observations with the ADON revealed there were no towel racks in all resident’s closets (see observation below).-However, according to resident interviews, there were no towel racks inside the closets and they did not receive hand towels unless they asked for them (see interviews above). V. Facility follow-upOn 2/26/26 at 3:15 p.m., the closets in room #222 and room #223 were observed with the ADON, who verified there were no towel racks in the residents; closets or in the bathroom. The resident who resided in room #223 told the ADON there were no towel racks in the closets or the bathroom.

Based on observations, record review and interviews, the facility failed to provide ongoing programs to support choices of activities and engaging programming based on the comprehensive assessment and care plan that were designed to meet the interests of and support the physical, mental, and psychosocial well-being of two (#46 and #55) of three residents reviewed for activities out of 41 sample residents. Specifically, the facility failed to offer and provide personalized meaningful activity programs for Resident #46 and Resident #55 as documented in their care plans. Findings include:I. Resident #46A. Resident statusResident #46, age greater than 65, was admitted on 7/28/25. According to the February 2026 computerized physician orders (CPO) diagnoses included unspecified dementia, mood disturbance and anxiety. The resident was in hospice care. The 2/18/26 minimum data set (MDS) assessment revealed the resident was moderately cognitively impaired with a brief interview for mental status (BIMS) score of nine out of 15. The resident was dependent on staff assistance for all activities of daily living (ADL) . The 3/14/21 MDS assessment revealed it was very important to the resident to listen to music, have animals around, keep up with the news and do her favorite activities. It was somewhat important to her to have books and magazines to read. B. Observations: On 2/23/26 at 12:10 p.m. Resident #46 was sitting in the dining room for lunch. Staff were assisting the resident with eating. There was no conversation being conducted with the resident while staff was assisting her with eating. During a continuous observation on 2/24/26, beginning at 1:58 p.m. and ending at 3:58 p.m. Resident #46 was lying in bed. There was no music playing in the resident’s room or any other type of meaningful activity. During a continuous observation on 2/25/26, beginning at 1:29 p.m and ending at 4:30 p.m. Resident #46 was again lying in bed. The resident did not have any meaningful activity while she was in her room. There was no music or television (TV) playing on the resident’s side of the room. The resident’s roommate had the TV on, however, Resident #46 laid in bed holding the daily chronicle (facility daily bulletin) folded in a square. At 4:07 p.m. the business office manager entered Resident #46’s room. The business office manager greeted Resident #46 and said she was in the room to check on the resident’s bird. The business office manager remained in the room for only a few minutes. Resident #46 asked the business office manager to stay and visit, as she wanted some company. However, the business office manager said she could not stay and left the room. -No staff members from the care or activities teams were observed to come to the resident, per her request, to provide a one-on-one activity for her or to keep the resident company after the staff member left. C. Record reviewReview of Resident #46’s activities care plan, updated 1/30/26, revealed the resident liked to watch TV, enjoyed visiting, her bird and reading the daily chronicle. Pertinent interventions were to assist the resident to activities of interest, encouraging the resident to participate in individual activities as desired. The activity assessment, dated 1/23/26, revealed Resident #46 liked to spend time in her room and attend group activities of her interest. She enjoyed religious prayer, arts and crafts, singing, parties, knitting and socializing. The assessment indicated that for attending the group activities, she needed more attention and encouragement. Review of Resident #46’s activity participation record (from 1/29/26 to 2/26/26) revealed the resident participated in independent activities and also received supplies for independent activities. However, there was no documentation of what independent activities the resident was provided with. There was no documentation in the resident’s participation record regarding group activities. II. Resident #55A. Resident statusResident #55 was admitted to the facility on 4/24/23. According to the February 2026 CPO, diagnoses included depression, difficulty walking and chronic pain. The 1/26/26 MDS assessment revealed the resident had no cognitive impairment with a BIMS score of 15 out of 15. The resident was independent with ADLS. The 4/18/26 MDS assessment revealed it was very important for the resident to get fresh air when the weather was good and to participate in her favorite activities. B. Resident interview Resident # 55 was interviewed on 2/23/26 at 2:30 p.m. Resident #55 said she had not been able to go on any facility bus rides or shopping trips to buy certain personal items because she used a wheelchair for mobility and the facility’s bus had a wheelchair lift that had been broken for a long time. The resident did not remember how long the lift had been broken for. She said she would really like to go on some of the outing activities. C. Record reviewReview of Resident #55’s care plan, updated on 12/30/25, revealed Resident #55 was independent with activities, however she liked the community outings. Pertinent interventions included inviting and assisting the resident to activities of choice. Review of Resident #55’s activity participation record (from 1/25/26 to 2/26/26) failed to reveal documentation to indicate the resident had participated in any activity outings. III. Staff interviewsThe activities director (AD) was interviewed on 2/25/26 at 11:41 a.m. The AD said she was newly hired to the facility. She said she was familiar with Resident #46. The AD said the resident liked to attend group activities, but she needed assistance to get to the activities. She said Resident #46 was receiving hospice care services. She said the activity department had staff coverage seven days a week, and that they were responsible for inviting the residents to group activities. She said Resident #46 received the facility’s daily chronicle every day and enjoyed religious activities and coloring. The AD said the resident was not on a one-to-one activity program but she would benefit from one. She said sensory stimulation would also benefit the resident, however, other than hand massages, this had not been tried with her. She said she had not gotten in touch with hospice volunteers for the resident to see if they could provide visits. She said the business office manager should have informed activities staff that Resident #46 wanted to visit rather than just leaving the room after the resident requested her to stay (see observations above). The AD said she scheduled trips to the local store weekly. She said the facility had a van, however, the wheelchair lift was broken. She said Resident #55 could not climb the stairs of the bus and therefore was unable to go on the activity outings to the store or scenic trips. She said the facility had made attempts to repair the bus, but the bus was still broken. She said she had not looked into the possibility of using a sister facility’s bus or the local city wheelchair bus so Resident #55 could attend outings. The AD confirmed that Resident #55 had requested to attend outings. The maintenance director (MTD) was interviewed on 2/25/26 at 4:20 p.m. The MTD confirmed the facility’s wheelchair lift on the bus was broken. He said the attempts to repair the ramp had failed. The MTD said he could always borrow the buses from the facility's sister communities if needed.

Based on observations, record review and interviews, the facility failed to ensure residents received treatment treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one (#67) of two residents reviewed out of 41 sample residents. Specifically, the facility failed to:-Ensure physician's orders were obtained for Resident #67’s insulin pump and that the insulin pump was being appropriately monitored; -Ensure Resident #67’s blood glucose (sugar) levels were being monitored; and,-Ensure Resident #67 received a carbohydrate-controlled diet, per her request. Findings include:I. Professional referenceAccording to the American Diabetes Association’s Check Your Blood Glucose - Diabetes Testing And Monitoring retrieved on 3/4/26 from https://diabetes.org/living-with-diabetes/treatment-care/checking-your-blood-sugar,“The logging of your blood glucose results is vital. When you bring your log to your health care provider, you will have a good picture of your body's response to your diabetes care plan.”II. Facility policy and procedureThe Insulin Therapy policy, dated March 2025, was provided by the nursing home administrator (NHA) on 2/26/26. The policy read in pertinent part, “The facility is to routinely assess residents who self manage their insulin therapy for their ongoing willingness and ability to do so safely and effectively. Residents who manage their glucose monitoring and/or insulin administration are routinely assessed for their ongoing willingness and ability to do so safely and effectively.”III. Resident #67A. Resident statusResident #67, age 71, was admitted on 2/19/26, post hospitalization for vertigo and continued dizziness. According to the February 2026 computerized physician orders (CPO), diagnoses included type 2 diabetes mellitus with diabetic neuropathy, and chronic obstructive pulmonary disease (COPD). Per the admission assessment, the resident was cognitively intact. B. Resident observations and interview On 2/23/26 at 4:30 p.m. Resident #67’s arm was observed with an attached Dexcom freestyle glucometer (blood sugar monitor that continuously monitors blood sugar levels) and an insulin pump attached to her left arm. The resident said she was newly admitted to the facility. She said she was a diabetic and she had to watch the carbohydrates that she ate. She said she was receiving a regular diet and not a carbohydrate controlled diet. She said she had been requesting a carbohydrate controlled diet, but nobody was listening to her. She said she had an insulin pump and a glucometer and the results went directly to her phone. She said she had had these devices for a while and was able to manage them. On 2/23/26 at 5:20 p.m. Resident #67 received her dinner meal tray; however, she did not receive a carbohydrate controlled meal. The resident’s meal tray ticket documented the resident was on a regular diet. Resident #67 was interviewed again on 2/24/26 at approximately 10:00 a.m. Resident #67 said she had changed her insulin pump earlier in the morning. She said the dexcom freestyle glucometer would read directly to her phone. She said the insulin pump would then automatically dispense the appropriate amount of insulin into her body. She said that none of the nurses from the facility had asked to see her blood sugar. levels She said that it was important for her to watch what she ate in order to keep her blood sugars in a manageable range. On 2/24/26 at 5:30 p.m. Resident #67 received cheese ravioli for dinner and a piece of cake, which was not a carbohydrate controlled diet. Resident #67 was interviewed a third time on 2/25/26 at 10:00 a.m. Resident #67 was being assisted to therapy by the physical therapy assistant. She said she did not receive the carbohydrate diet again for breakfast. She said she had not been receiving the controlled carbohydrates as she requested and needed because of her diabetes since she was admitted to the facility. C. Record reviewThe 2/19/26 hospital records revealed Resident #67 was discharged from the hospital to the facility with the following physician’s orders:Insulin aspart 100 units/milliliter (ml) solution pump. Inject into the skin continuously via Omnipod (insulin pump) as directed. The discharge hospital records additionally indicated the resident should eat a carbohydrate controlled diet with a maximum of 25 percent (% )to 50% of the calories to come from carbohydrates for each meal. -Review of Resident #67’s February 2026 CPO failed to reveal the resident had a physician’s order for the insulin pump. -The February 2026 CPO failed to reveal that the resident had a physician’s order to monitor the resident's blood glucose levels and the use of the dexcom glucometer. -The February 2026 CPO failed to reveal physician’s orders to monitor the resident’s insulin pump for any dysfunction or complications. -Review of the February 2026 CPO revealed the resident had a physician’s order for a regular diet (not a carbohydrate controlled diet). -There was no documentation in Resident #67’s EMR to indicate the facility had attempted to obtain appropriate monitoring orders from the physician (see DON interview below). The at-risk review note, dated 2/20/26, documented staff were to monitor Resident #67’s blood glucose levels, insulin pump functionality , and observe for signs and symptoms of low or high blood sugar levels. -However, review of Resident #67’s electronic medical record (EMR) did not reveal documentation to indicate the facility was monitoring the resident’s blood glucose levels, insulin pump or signs and symptoms of low or high blood sugar levels. A review of Resident #67’s meal tray ticket on 2/25/26 revealed the resident’s diet order had been changed from a regular diet to a carbohydrate controlled diet (during the survey). IV. Staff interviewsLicensed practical nurse (LPN) #1 was interviewed on 2/25/26 at 9:56 a.m. LPN #1 said she was the admitting nurse when Resident #67 was admitted to the facility on 2/219/26. She said the resident was admitted from the hospital due to vertigo. LPN #1 confirmed Resident #67 had a diagnosis of diabetes and that she had an insulin pump which she managed on her own. She said the blood glucose levels went to the resident’s phone. She said she had not asked to see the resident’s phone to monitor her blood sugar levels, however, she said she had not worked since the resident was admitted to the facility. LPN #1 reviewed Resident #67’s EMR and confirmed that there was no documentation in the resident’s EMR related to the resident’s blood sugars. She additionally confirmed, after reviewing the resident’s EMR, that there was no physician’s order to monitor Resident #67’s blood sugars or a physician’s order for the resident’s insulin pump. LPN #1 said she would have another nurse call the physician for the orders. Registered nurse (RN) #2 was interviewed on 2/26/26 at 1:00 p.m. RN #2 said she had phoned the physician for the insulin pump and blood glucose monitoring physician’s orders for Resident #67. She said she had not seen the physician’s order on the hospital discharge record for the carbohydrate controlled diet and the physician ordered a regular diet. RN #2 said Resident #67 managed the insulin pump and the freestyle glucometer herself and was planning on only being at the facility for a few weeks, therefore, she thought it was okay that the monitoring orders were not in the February 2026 CPO. The assistant director of nursing (ADON) and the director of nursing (DON) were interviewed together on 2/26/26 at 2:10 p.m. The ADON confirmed there were no physician’s orders for the blood glucose monitoring and the insulin pump in Resident #67’s EMR. She said a physician’s order for both devices obtained on 2/25/26 (during the survey). The DON said she had attempted to call the physician for orders however, had not received. -However, review of Resident #67’s EMR did not reveal any documentation of the DON’s attempts to call the physician (see record review above). The ADON said she was responsible for reviewing residents’ EMRs after they were admitted to the facility to ensure all physicians orders were in place; however, she had not reviewed Resident #67’s EMR yet. V. Facility follow-upA second review of Resident #67’s EMR on 2/25/26 revealed physician’s orders had been obtained for monitoring the resident’s blood sugar levels and the insulin pump. Additionally, a blood sugar value of 370 mg/dl (milligrams per deciliter) was recorded in the EMR on 2/25/26 at 11:30 a.m.-However, the physician’s orders were not obtained for monitoring the insulin pump and recording the resident’s blood sugar levels until the concern was brought to the facility’s attention during the survey.

Based on observations, record review and interviews, the facility failed to provide necessary services consistent with professional standards of practice to promote healing of pressure injuries and prevent of additional pressure injuries for one (#46) of two residents out of 41 sample residents. Specifically, the facility failed to:-Ensure Resident #46, who had pressure injuries, was repositioned and provided incontinence care in a timely manner; and,-Ensure staff consistently implemented care planned pressure injury prevention interventions for Resident #46. Findings include:I. Professional referenceAccording to Basic Nursing third edition; Leslie S. Treas, Karen Barnett, Mable H. Smith (2022), page 1214-1215, “Healthy people regularly shift position to maintain comfort. However, many patients are unable to move without assistance. They require a change of position at least every two hours to prevent skin breakdown, muscle discomfort. People who are immobile are more prone to pressure injury as a result of reduced circulation, impaired oxygen exchange to the tissues and edema.”According to the National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline, Emily Haesler (Ed.), Cambridge Media: Osborne Park, Western Australia; 2014, retrieved from https://www.ehob.com/media/2018/04/prevention-and-treatment-of-pressure-ulcers-clinical-practice-guidline.pdf on 2/10/22, "Pressure ulcer classification is as follows:Category/Stage 1: Nonblanchable Erythema Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage I may be difficult to detect in individuals with dark skin tones. May indicate "at risk" individuals (a heralding sign of risk). Category/Stage 2: Partial Thickness Skin Loss Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising.* This Category/Stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. *Bruising indicates suspected deep tissue injury. Category/Stage 3: Full Thickness Skin Loss Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/Stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/Stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable. Category/Stage 4: Full Thickness Tissue Loss Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a Category/Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Category/Stage 4 ulcers can extend into muscle and/or supporting structures (fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable. Unstageable: Depth Unknown Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/Stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as 'the body's natural (biological) cover' and should not be removed. Suspected Deep Tissue Injury: Depth Unknown Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment."II. Resident #46A. Resident statusResident #46, age greater than 65, was admitted on 7/28/25. According to the February 2026 computerized physician orders (CPO), diagnoses included unspecified dementia, mood disturbance and anxiety. The 2/18/26 minimum data set (MDS) assessment revealed the resident was moderately cognitively impaired with a brief interview for mental status (BIMS) score of nine out of 15. The resident was dependent on staff assistance for all activities of daily living (ADL). The MDS assessment indicated the resident was at risk for developing pressured injuries and had at least one unhealed pressure injury. B. ObservationsOn 2/23/26 at 11:50 a.m. Resident #46 was being assisted to the dining room. The resident’s feet were resting on her wheelchair foot pedals, however, she did not have the protective boots on her feet. She was not wearing shoes and her sock feet were resting directly on her foot pedals. During a continuous observation on 2/24/26, beginning at 1:58 p.m. and ending at 5:20 p.m., the following was observed:At 1:58 p.m. Resident # 46 was sleeping on her back in bed. At 2:33 p.m. the resident continued to be in the same position, lying on her back with no repositioning. There were no positioning wedges observed in the room, and the resident did not have protective boots on her feet. The resident’s heels were resting directly on the mattress. At 3:58 p.m. Resident #46 continued to lay on her back in bed with no repositioning offered by staff. At 5:20 p.m. the resident continued to lay on her back in bed. There had been no staff members in the resident’s room to offer her repositioning with wedges or place protective boots on her feet. During a continuous observation on 2/25/26, beginning at 1:29 p.m. and ending at 4:30 p.m. the following was observed:At 1:29 p.m. Resident #46 was laying in bed on her back with her head slightly raised., There were no positioning wedges offloading the resident. At 2:35 p.m., the resident continued to lay on her back in bed with her head slightly raised.-No staff members had entered the room to provide incontinence care and repositioning to the resident. At 4:22 p.m. registered nurse (RN) #1 and RN #2 entered Resident #46’s room to provide wound care for the resident. The nurses proceeded to uncover the resident in order to perform wound care. The resident’s heels did not have protective boots on and her heels were lying directly on the mattress. RN #2 proceeded to open the resident’s brief and perform wound care on the resident’s sacrum pressure wound while RN #1 assisted. The stage 3 pressure injury on the resident’s sacrum was cleaned with normal saline, patted dry, and medihoney ointment (wound treatment) was applied and the wound was covered with a dressing, per the physician’s order. RN #2 began to close the resident’s brief after finishing the wound care on the resident’s sacrum. When prompted, RN #2 changed Resident #46’s brief and said the resident was wet. After changing the resident’s brief, RN #1 proceeded to perform the wound care on the resident’s right heel. The unstageable pressure injury on the resident’s right heel was cleaned with normal saline and covered with a dressing, per the physician’s order. Before leaving the resident’s room, RN #1 put Resident #46’s protective boots on the resident. The resident allowed the application of the boots. On 2/26/26 at 8:30 a.m. Resident #46 was in the dining room for breakfast. The resident did not have protective boots on her feet. Resident #46’s heels were resting directly on the wheelchair foot pedals. C. Record ReviewReview of Resident #46’s pressure injury care plan, updated 1/28/26, identified the resident had a deep tissue injury to the right heel and a stage 3 pressure ulcer to the sacrum. Pertinent interventions included monitoring the wounds per facility protocol with offloading, treatment orders, applying heel protecting boots and offloading heels while the resident was in bed and applying heel protecting boots while the resident was up in her chair as well to prevent pressure injuries and encouraging and assisting the resident with turning and repositioning frequently while in bed, and as tolerated. The nurse progress note, dated 1/28/26, revealed the development of a new pressure injury on the resident’s right heel. The progress note documented new interventions included heel offloading by pillows/heel protectors to prevent further pressure injuries and putting the resident on a repositioning schedule.-However, observations revealed staff were not consistently offloading the resident’s heels or providing timely repositioning to the resident (see observations above). The nurse progress note, dated 2/10/26, revealed the resident developed a new sacral pressure injury and the wound care physician had determined that it was an unavoidable pressure injury. Per the progress note, the facility initiated frequent rounding to reinforce skin care and repositioning as tolerated, maintaining pressure-relief interventions, including low air-loss mattress, heel offloading boots, pillows, and positioning wedges for side-lying/offloading as tolerated by the resident, encouraging oral intake and supplements as tolerated, continuing frequent repositioning attempts with gentle re-approach due to refusals,and honoring resident preferences and comfort-focused goals. The wound tracking evaluation, dated 2/17/26, revealed Resident #46 had a stage 3 pressure injury on the sacral area with dimensions of 4 centimeters (cm) by 3 cm by 0 cm, initiated on 2/9/26, and a closed unstageable right heel with dimensions of 3 cm by 4 cm by 0 cm, initiated on 1/28/26. D. Staff interviews: Registered nurse (RN) #3 was interviewed on 2/26/26 at 10:22 a.m. RN #3 said Resident #46 had a pressure injury on her sacrum and one on her right heel. She said the resident was at high risk for pressure injuries due to immobility and incontinence. She said Resident #46 was to be checked on frequently. She said the resident was to have the foot protection boots and was to be repositioned when she was in bed. RN #2 was interviewed on 2/26/26 at 10:30 a.m. RN #2 said the repositioning requirements for Resident #46 had been added to the medication administration records (MAR), in order to ensure the resident was being repositioned. RN #2 said the staff had been in-serviced about the importance of residents being repositioned every two hours. She said if Resident # 46 refused repositioning, staff should document the refusal. The assistant director of nursing (ADON) was interviewed on 2/26/26 at 11:09 p.m. The ADON said she was the wound care nurse and she completed wound care rounds with the wound care physician. She said the wound care physician measured the residents’ wounds, and made any changes to wound treatments in the physician’s orders. The ADON said Resident #46’s wounds were classified as unavoidable due to her comorbidities. She said the resident should have the interventions of the heel protectors on her heels at all times and staff should be repositioning the resident every two hours.

Based on observations, record review and interviews, the facility failed to ensure the environment were free of accidents and hazards for one (#11) of two residents reviewed for accidents out of 41 sample residents and three of three emergency crash carts. Specifically, the facility failed to:-Ensure Resident #11 was assessed to determine if he was safe to smoke independently after an incident of unsafe smoking; and,-Ensure medical grade power strips were readily available in the crash carts (a specialized, mobile, and organized unit of trays and drawers on wheels containing essential life-saving equipment and medications). II. Failed to ensure medical grade power strips were readily available in the crash cartsA. ObservationsThe facility’s three crash carts were observed on 2/25/26. The following was found:At 3:50 p.m. there was a commercial power strip found in the crash cart in the basement. The power strip was not a medical grad power strip. At 3:55 p.m. there was no power strip found in the crash cart on the first floor. At 4:00 p.m. there was a commercial power strip in the crash cart on the second floor. The power strip was not a medical grade power strip. The suction machine functioned appropriately. The facility’s crash carts were observed again with the maintenance director (MTD) on 2/26/26. The following was found:At 11:12 a.m. the commercialized power strip in the basement crash cart was replaced with a medical grade power strip by the MTD.At 11:14 a.m. a medical grade power strip was placed in the first floor crash cart by the MTD. At 11:16 a.m. the commercialized power strip in the second floor crash cart was replaced with a medical grade power strip by the MTD.B. Staff interviewsThe MTD was interviewed on 2/26/26 at 11:16 a.m. The MTD said it was important to use medical grade power strips in the emergency crash carts because the commercial power strips had 20 amperes (amps; the standard unit for measuring electric current). He said the more amps, the more heat could be trapped and could cause a fire. The MTD said the medical grade power strips had 15 amps and created less heat, which decreased the risk of fire. The assistant director of nursing (ADON) and the director of nursing (DON) were interviewed together on 2/26/26 at 4:50 p.m. The ADON and the DON said the night nurses checked the crash carts nightly, the respiratory nurse checked them at least daily and the ADON checked the crash carts daily as a part of her morning rounds. The DON said she would expect to see a medical grade power strip stocked in the facility’s crash carts so the power strip had enough power to handle the emergency equipment. C. Facility follow-upThe MTD replaced the commercial power strips with medical grade power strips during the tour of the facility’s crash carts on 2/26/26 beginning at 11:12 a.m.-However, the commercial power strips were not replaced with medical grade power strips in the crash carts until the concern was brought to the attention of the facility during the survey.

Based on observations, record review and interviews, the facility failed to ensure residents received necessary respiratory care and services per professional standards of practice for two (#24 and #67) of three residents reviewed for respiratory care out of 41 sample residents. Specifically, the facility failed to:-Ensure the physician’s order matched the resident's preference for oxygen administration for Resident #24; and,-Ensure there was a physician’s order for oxygen use for Resident #67. III Resident # 67 A. Resident statusResident #67, age 71, was admitted on 2/19/26.. According to the February 2026 CPO diagnoses included type 2 diabetes mellitus with diabetic neuropathy, and chronic obstructive pulmonary disease (COPD). According to the resident’s Level I Pre-Admission Screening and Resident Review (PASRR) assessment, the resident was cognitively intact. B. Observations On 2/23/26 at 4:30 p.m. Resident #67 was sitting in bed. She was wearing a nasal cannula and her oxygen was set to 3 liters per minute (LPM). On 2/25/26 at 11:23 a.m. Resident #67’s oxygen was set to 2.5 LPM.C. Record review A review of Resident #67’s February 2026 CPO on 2/25/26 revealed the resident had no physician’s order for oxygen therapy. The progress note, dated 2/20/26, documented Resident #67 was started on oxygen at 2 LPM via nasal cannula. D. Staff interviewLPN #1 was interviewed on 2/25/26 at 9:56 a.m.. She said Resident #67 was on oxygen therapy for her diagnosis of COPD. She confirmed oxygen was considered a medication and required a physician’s order to administer it. After reviewing Resident #67’s physician’s orders, LPN #1 said she was not able to locate the physician's order for the resident’s use of oxygen. E. Facility follow-up A second review of Resident #67’s February 2026 CPO on 2/26/26 revealed a physician’s order for oxygen administration was obtained on 2/25/26 at 10:46 a.m. -However, the physician’s order for Resident #67’s oxygen administration was not obtained until the concern was brought to the facility’s attention during the survey.

Based on observations, record review and interviews, the facility failed to provide an effective pain management regimen in a manner consistent with professional standards of practice, resident-centered care plans, and resident preferences for one (#37) of two residents out of 41 sample residents. Specifically, the facility failed to: -Ensure a complete and thorough pain assessment was completed that identified Resident #37’s history of pain and its treatment, history of addiction, characteristics of pain and the impact of pain on the resident’s quality of life; -Identify Resident #37’s goals for pain management and acceptable level of pain; -Identify Resident #37’s locations of pain; and, -Ensure Resident #37’s location of pain was consistently identified when administering pain medication to the resident. Findings include: I. Facility policy and procedureThe Pain Management policy, revised June 2022, was provided by the nursing home administrator (NHA) on 2/26/26 at 6:46 p.m. It read in pertinent part, “The facility will evaluate and identify residents experiencing pain, evaluate the existing pain and the use, determine the type and severity of the pain and develop a care plan for management consistent with the resident’s goals and preferences. The care plan is implemented and evaluated for its effectiveness. The staff monitors and documents the resident’s response to pain management interventions. Pain screening is conducted upon admission, quarterly and annually thereafter using the pain evaluation. The goal of the pain management system is to effectively and consistently identify and treat pain.”II. Resident #37 A. Resident status Resident #37, age 69, was admitted on 9/28/25. According to the February 2026 computerized physician orders (CPO), diagnoses included chronic pain syndrome, malignant neoplasm of rectum and rectosigmoid junction (cancer located in the lower part of the large intestine where the colon meets the rectum), obesity, major depressive disorder, peripheral vascular disease (a circulatory condition that reduces blood flow to the arms or legs), chronic obstructive pulmonary disease (COPD - a long-term lung disease that makes it difficult to breathe due to airflow blockage), unilateral inguinal hernia (a condition where tissue pushes through a weak spot in the abdominal muscles on one side of the groin), osteoarthritis, spinal stenosis (narrowing of the spaces within the spine), acute kidney failure, benign prostatic hyperplasia (BPH - noncancerous enlargement of the prostate gland that can cause urinary problems) and hypoxemia (lower-than-normal levels of oxygen in the blood). The 1/20/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. He was independent with eating, oral hygiene, toileting and personal hygiene. He required partial assistance with showering. The assessment revealed Resident #37 did not have a pain management regimen. He took pain medication as needed and received non-medication interventions for pain. He had pain in the past five days of the look back assessment period. The assessment revealed the resident’s pain occasionally occurred and occasionally made it difficult to sleep and occasionally limited his day to day activities because of pain. A numeric scale was completed for pain intensity and his worst pain was a 3 on a scale of 0 to 10. The resident said his pain intensity was described as mild. B. Resident interview Resident #37 was interviewed on 2/23/26 at 3:23 p.m. Resident #37 said he had been prescribed oxycodone (opioid pain medication) for the last eight years due to surgery he had on his neck. He said he used to ride his bike five to ten miles a day but could no longer do so because of the pain. He said his physician wanted to discontinue all oxycodone orders. He said he used to be on oxycodone 20 milligrams (mg) three times a day and now he was on oxycodone 10 mg every 12 hours. Resident #37 said if the physician stopped prescribing his oxycodone he had ways of obtaining oxycodone. He said he knew people on the street and that was what he had been doing since his physician changed his oxycodone order. He said yesterday, 2/22/26, he bought two 5 mg oxycodone tablets on the street in addition to the oxycodone administered by the facility. Resident #37 said he experienced pain where his hernia was located as well as abdominal pain. He said he had abdominal surgery because his intestines were twisted. Resident #37 lifted his shirt and showed the surgical scar that was vertically along his abdomen, extending from a few inches above his belly button to a few inches below his belly button. He said his physicians and nurses asked him if he knew he had a hernia and he said he knew because he was reminded of it all day because of the pain. Resident #37 said he additionally had pain in both knees. He said he had cancer and the chemotherapy damaged the ligaments in his knees. He said his current pain level was a 6 out of 10 and increased to an 8 on some days. He said his goal for pain management was to have a pain level of 0. He said his goal was to be able to return to his previous lifestyle as much as possible. C. Record review Resident #37’s pain care plan, revised 9/29/25, revealed he had acute pain related to an abdominal incision from a colon resection, history of cervical spine fusion, carpal tunnel syndrome, spinal stenosis and COPD. Interventions included administering analgesia (pain relief) as ordered, monitoring and recording pain characteristics every shift and as needed, monitoring and reporting to nurse any signs and symptoms of non-verbal pain, and notifying the physician if interventions were unsuccessful or if the current complaint was a significant change from the resident's past experience of pain. -The care plan did not include non-pharmacological interventions, monitoring for pain medication effectiveness, and monitoring for side effects of opioid (a class of natural, man-made, or semi-synthetic chemical compounds that interact with opioid receptors on nerve cells in the body and brain to reduce the intensity of pain signals) use. The 10/6/25 pain assessment revealed Resident #37 had pain in the last five days. He had a pain management regime, he took pain medication as needed and he received non-medication interventions for pain. The assessment documented the resident’s pain rarely occurred, rarely interfered with therapy activities and rarely interfered with his day-to-day activities. A numeric scale was completed for pain intensity and his worst pain was a 3 on a scale of 0 to 10. -However, the treatment, side effects and effectiveness of pain medications sections were left blank for the scheduled pain medication regimen. The administration patterns, side effects and effectiveness sections were left blank. The non-medication interventions and effectiveness section was left blank. The 1/7/26 pain assessment revealed Resident #37 had had pain in the last five days. He took pain medication as needed and he received non-medication interventions for pain. The assessment documented his pain occasionally occurred, occasionally interfered with sleep and occasionally interfered with his day-to-day activities. A numeric scale was completed for pain intensity and his worst pain was a 3 on a scale of 0 to 10. -However, the administration patterns, side effects and effectiveness sections were left blank for pain medication as needed. The non-medication interventions and effectiveness section was left blank. Resident #37’s February 2026 CPO revealed the following physician’s orders: Oxycodone 5 mg. Take one tablet by mouth every four hours as needed for moderate to severe pain, ordered 9/28/25 and discontinued 1/16/26. Oxycodone 5 mg. Take one tablet by mouth every six hours as needed for moderate to severe pain for 14 days, ordered 1/16/26 and discontinued 2/10/26. Oxycodone 5 mg. Take one tablet by mouth every eight hours as needed for moderate to severe pain, ordered 1/16/26 and discontinued 2/10/26. Oxycodone 5 mg. Take one tablet by mouth every 12 hours as needed for a pain level of 5 to 10, ordered 2/10/26. Cymbalta 60 mg. Take one capsule by mouth one time a day for pain, ordered 9/29/25 and stopped 10/9/25. Cymbalta 60 mg. Take one capsule by mouth one time a day for pain and depression, ordered 10/9/25. Gabapentin 300 mg. Take two capsules by mouth at bedtime for pain, ordered 9/29/25. Acetaminophen. Take 1000 mg by mouth every six hours as needed for pain. Maximum dose is less than 3000 mg, ordered 12/5/25. Document nonpharmacological interventions attempted prior to pain medication using the key provided every shift. Repositioning, reassurance, distraction, exercise, rest, deep breathing exercises, massage, guided imagery, laughter, socialization, aromatherapy or other, ordered 9/28/25. Evaluate pain utilizing the 0 to 10 pain scale as appropriate for the resident every shift for pain management, ordered 9/28/25. -Review of Resident #37’s electronic medical record (EMR) did not reveal documentation indicating if the non-pharmacological pain interventions were effective. The 1/1/26, 1/2/26, 1/3/26, 1/5/26, 1/7/26, 1/8/26, 1/10/26, 1/14/26, 1/16/26, 1/17/26, 1/24/26, 1/25/26, 1/29/26, 1/31/26, 2/6/26, 2/7/26, 2/14/26, 2/21/26 and 2/24/26 nurse notes revealed Resident #37 was administered oxycodone 5 mg. The 1/9/26 and 1/30/26 nurse notes revealed the resident was administered acetaminophen 1000 mg. -However, there was no documentation indicating where the pain was located when the oxycodone 5 mg or acetaminophen 1000 mg were administered between 1/1/26 and 2/24/26. - A review of Resident #37’s EMR revealed the non-pharmacological interventions were not determined as a personalized pain management intervention for the resident. The 12/9/25 physician notes revealed Resident #37 had a history of spinal stenosis, cervical spondylotic myeloradiculopathy (age-related spinal cord compression), myelopathy (spinal cord compression causing nerve symptoms) and degenerative disc disease of the cervical spine. Treatment had included decompression, discectomy (surgical disc removal), laminectomies (spinal decompression surgery), and spinal fusion. The resident had peripheral neuropathy (nerve numbness that causes pain) due to and not concurrent with chemotherapy, as well as baseline neuropathy related to cervical and lumbar spine conditions. Chemotherapy and radiation had been completed in October 2020, with chemotherapy discontinued due to neuropathy. The resident had ulnar neuropathy at the elbow of the left upper extremity (nerve damage or irritation affecting the elbow and arm). Additionally, the resident had chronic bilateral knee pain, including osteoarthritis of the right knee and chronic left knee pain. Pain had been reported as fairly well controlled with acetaminophen (Tylenol) 1000 mg every six hours as needed, duloxetine (Cymbalta) 60 mg daily, gabapentin 600 mg at bedtime, and oxycodone 5 mg every four hours as needed. The resident had been scheduled to see pain management on 12/22/25. He had additionally been scheduled for surgery on the left arm and wrist on 1/27/26, with plans to continue coordination of care with orthopedics. Therapies and supportive care had been continued as indicated. The 1/16/26 physician note revealed there was an update from the pain management clinic indicating the resident was discharged from the pain management clinic due to a toxicology screen in December 2025 being positive for methamphetamine (often called "meth" or "crystal meth," is a potent and highly addictive synthetic stimulant drug that affects the central nervous system). The urinalysis was reviewed with the resident and was positive for methamphetamines. It was reported that the office would be discharging the resident from their practice due to this result. The resident was educated that he continued to receive oxycodone as needed; however, due to the positive drug screen and for his safety, the medication would need to be gradually weaned. The resident voiced understanding. He communicated to multiple people at the office he would find oxycodone off the street if needed. The resident was educated on the risk of overdose, death or injury by using drugs purchased on the street. The 1/21/26 physician’s social worker note revealed Resident #37 said pain management dropped him and he would no longer receive pain medication after 1/30/26 due to him “popping hot” (testing positive for methamphetamine in a toxicology screen). The resident reported he was unsure what the plan was to manage his pain starting at the beginning of next month (February 2026). He reported he did not understand the reason pain management discharged him. Shortly after stating that, he mentioned this was discussed with his physician during their visit as well as informed risk regarding taking certain medications while utilizing illicit drugs. The 2/10/26 physician note revealed Resident #37 reported pain in his hands, knees and from hernias. His pain control was unclear. He was likely using methamphetamine and likely using opioids he got from the street. Concurrent use of methamphetamine and opioids was not safe and they would continue to wean the resident off oxycodone. The plan was to decrease oxycodone to 5 mg every 12 hours as needed.-However, the facility failed to ensure other non-opioid medications were implemented in place of the oxycodone medication that was being weaned in order to ensure Resident #37 was able to achieve effective pain management without the opioid medication. III. Staff interviewsCertified nurse aide (CNA) #4 was interviewed on 2/26/26 at 10:47 a.m. CNA #4 said today (2/26/26) was her first day working in the facility. She said if a resident reported pain, she asked the resident where the pain was located and reported the pain to the nurse. CNA #4 said she was not sure if CNAs documented pain at this facility, but some facilities had CNAs document pain in their daily charting. CNA #4 said she met Resident #37 this morning and he was not happy. She said he did not report any pain to her. She said she did not know what helped his pain go away or what made his pain worse. CNA #5 was interviewed on 2/26/26 at 11:03 a.m. CNA #5 said if a resident reported pain to him, he asked the resident to rate their pain and where they experienced pain. He said he told the resident he informed the nurse. He said he asked the nurse if they could assess the resident due to what the resident reported to him. He said he did not document if a resident reported pain to him. CNA #5 said he was familiar with Resident #37. He said he had pain in his back and legs. CNA #5 said pain medication helped the resident and sometimes something cold to drink or coffee helped alleviate his pain. He said Resident #37 talking to his family or friends on the phone helped him with his pain. Licensed practical nurse (LPN) #1 was interviewed on 2/26/26 at 11:30 a.m. LPN #1 said pain assessments were completed when the residents were admitted, quarterly and as needed. She said pain was documented on an assessment form in their EMRs. She said the pain assessment documented where a resident’s pain was located, the intensity of the pain, what medications were used for pain before, what worked for relieving the pain and what did not work to help the resident get to baseline. She said she asked what non-pharmacological interventions worked for pain relief. She said she asked what their baseline goal level for pain was and what their acceptable pain level was. LPN #1 was familiar with Resident #37. She said he had pain and he complained about pain a lot. She said he had pain in his hands, wrists and his lower back. She said sometimes he had a headache. She said his goal was to be pain free or a 0 out of 10 pain level. She said he did not complain about pain everyday but approximately 75% of the time,he complained about pain. She said he had pain since she started working at the facility in December 2025. She said too much exertion made his pain worse, such as going outside and therapy. LPN #1 said if Resident #37 used his wheelchair too much, his pain in his hands would hurt. She said he never asked for pain medications for his knees or abdominal incision, she said it was mostly for his hands and wrists. The director of nursing (DON) was interviewed on 2/26/26 at 5:00 p.m. The DON said pain assessments were completed when the residents were admitted, quarterly and as needed. She said pain was documented on an assessment form in their EMRs. She said the assessment covered where the pain was located, the intensity of the pain, what worked for treating the pain and what did not work to help the resident get to baseline. She said she asked what non-pharmacological interventions worked for pain relief. She said she asked what their baseline goal level for pain was and what their acceptable pain level was. The DON said she was familiar with Resident #37. She said he had pain in his hands due to carpal tunnel syndrome. She said he rarely complained about pain. The DON said he was mostly outside of the building smoking. She said his pain management was to not have any pain. She said he had been in pain since he was admitted to the facility. She said his physician was not a facility physician and the physician decreased his pain medications. IV. Facility follow up The NHA provided the following information on 2/27/26 at 3:57 p.m., after the survey exit. Per the NHA, the documentation provided revealed the facility’s diligence in monitoring Resident #37’s pain, offering pain medication as needed and non-pharmacological interventions each time he voiced his pain concerns. According to the documentation, it was effective in managing his pain levels at those times. The documentation included the 2/10/26 physician’s progress note indicating the resident tested positive for methamphetamines, the resident admitted to using methamphetamine and buying oxycodone off the street (see record review above). He said he typically took 10 mg more oxycodone than what he received from the physician. The 1/7/26 pain assessment for Resident #37 was provided which highlighted the resident’s pain frequency as occasional. Resident #37’s January 2026 MAR was provided and highlighted that nonpharmacological interventions were utilized, the resident’s pain was evaluated every shift and acetaminophen and oxycodone were administered when requested by the resident.-However, the documentation did not indicate Resident #37’s pain assessment was complete, identify what the resident’ pain management goals were, identify all pain locations or indicate the location of pain was identified when administering pain medication to Resident #37.

Based on observations and interviews, the facility failed to ensure all drugs and biologicals were properly stored, secured, and labeled in accordance with accepted professional standards in two of two medication carts. Specifically, the facility failed to ensure residents’ medications were labeled and dated appropriately with the resident’s name and the date the medication was opened. Findings include:I. Facility policy and procedureThe Medication Labeling and Storage policy, dated February 2023, was provided by the nursing home administrator (NHA) on 1/26/26 at 9:23 p.m. It read in pertinent part, “Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices. “The medication label includes, at a minimum: medication name (generic and/or brand); prescribed dose; strength; expiration date, when applicable; resident’s name; route of administration; and, appropriate instructions and precautions.”II. ObservationsOn 2/26/26 at 8:48 a.m. the second floor medication cart was observed with licensed practical nurse (LPN) #1. The following items were found:There was one umeclidinium-vilanterol (Anoro Ellipta) inhalation aerosol powder breath activated 62.5-25 micrograms (mcg) per actuation (mcg/act) inhaler stored in an appropriately labeled medication box. -However, the individual inhalation device inside the box was not labelled with the resident’s name or the date the medication was opened for Resident #62. There was one fluticasone-umeclidinium-vilanterol (Trelegy Ellipta) inhalation aerosol powder breath activated 100-62.5-25 mcg/act inhaler stored in an appropriately labeled medication box. -However, the individual inhalation device inside the box was not labelled with the date the medication was opened for Resident #67. There was one bottle of Systane long-lasting ophthalmic (eye) drops stored in an appropriately labeled medication box. -However, the individual medication bottle inside the box was not labelled with the resident’s name or the date the medication was opened for Resident #60. On 2/26/26 at 10:08 a.m. the back hall medication cart on the first floor was observed with registered nurse (RN) #3. The following items were found:There was one dimethyl fumarate (Tecfidera) delayed release (DR) 240 milligram (mg) oral medication stored in an appropriately labeled medication box. -However, the individual medication bottle inside the box was not labelled with the resident’s name or the date the medication was opened for Resident #24. There was one GenTeal severe 0.3 percent (%) ophthalmic gel stored in an appropriately labeled medication box.-However, the individual medication bottle inside the box was not labelled with the resident’s name or the date the medication was opened for Resident #51. There was one umeclidinium-vilanterol (Anoro Ellipta) inhalation aerosol powder breath activated 62.5-25 mcg/act inhaler stored in an appropriately labeled medication box. -However, the individual inhalation device inside the box was not labelled with the resident’s name or the date the medication was opened for Resident #61. There was one Albuterol sulfate hydrofluoroalkane (HFA) inhalation aerosol solution 108 (90 base) mcg/act inhaler stored in an appropriately labeled medication box. -However, the individual inhalation device inside the box was not labelled with the resident’s name or the date the medication was opened for Resident #40. There was one Morphine sulfate immediate release (IR) 20 milligram per milliliter (mg/ml) oral solution stored in an appropriately labeled medication box. -However, the individual medication bottle inside the box was not labelled with the resident’s name or the date the medication was opened for Resident #4. III. Staff interviewsLPN #1 was interviewed on 2/26/26 at 8:48 a.m. LPN #1 said medications should be labelled inside their respective boxes. She said it was important for the medications to be labelled inside the boxes in case the box was damaged by water or other liquids in the medication cart. RN #3 was interviewed on 2/26/26 at 10:08 a.m. RN #3 said the medications should be labelled inside their respective boxes so the medications did not get mixed up if the boxes were destroyed. The assistant director of nursing (ADON) was interviewed on 2/26/26 at 11:27 a.m. The ADON said she would have expected to see the medications labelled inside their medication boxes, because any medication could go in any medication box. She said this could cause a medication error. The director of nursing (DON) and the ADON were interviewed together on 2/26/26 at 4:50 p.m. The DON said it was important for medications to be labelled inside their respective boxes because the medication inside could become separated from its box. She said an unlabelled medication without its box could potentially cause a medication error, since the nursing staff would not know who the medication belonged to.

Based on observations, record review and interviews, the facility failed to ensure one (#30) of three residents reviewed for ancillary services out of 41 sample residents received dental services timely. Specifically, the facility failed to: -Ensure Resident #30 was provided timely emergency dental services after reporting tooth pain; and, -Ensure Resident #30 was offered routine dental care. Findings include: I. Facility policy and procedure The Dental Services policy and procedure, revised December 2016, was provided by the nursing home administrator (NHA) on 2/26/26 at 6:46 p.m. It read in pertinent part, “Routine and 24-hour emergency dental services are provided to the residents through a contract agreement with a licensed dentist that comes to the facility monthly, referral to the resident’s personal dentist, referral to community dentist or referral to other health care organizations that provide dental services. Selected dentists must be available to provide follow up care. Failure of a dentist to provide follow up services will result in the facility’s right to use its consultant dentist to provide the resident’s dental needs. Social services representatives assist residents with appointments, transportation arrangements and for reimbursement of dental services under the state plan, if eligible. All dental services provided are recorded in the resident’s medical record.”II. Resident #30 A. Resident status Resident #30, age 81, was admitted on 7/5/23. According to the February 2026 computerized physician orders (CPO), diagnoses included osteoarthritis, chronic pain syndrome, hyperlipidemia, polyneuropathy, insomnia, major depressive disorder, generalized anxiety disorder and post traumatic anxiety disorder. The 1/19/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She required a wheelchair. She was independent with eating, oral hygiene, toileting, showering, and personal hygiene. The MDS assessment indicated the resident had no dental issues. B. Resident interview and observation Resident #30 was interviewed on 2/24/26 at 10:32 a.m. Resident #30 said she had to have a tooth pulled on 2/25/26. She said she needed to see a dentist because it had been a while. During the interview, Resident #30 was observed visibly in pain on her right side of her face, specifically her cheek and jawline. She had her head titled down to her right shoulder while being interviewed. When asked if she was in pain, Resident #30 said she was in pain and on a pain scale of zero to 10, zero being no pain, her pain level was currently an 8. Resident #30 asked to end the interview because of her pain, and she did not want to talk. There was a white caked substance observed on her upper front teeth. C. Record review The informed consent for dental, audiology and optometry services revealed Resident #30 signed the consent on 12/1/25. The 12/9/25 physician progress note revealed that Resident #30 was asked not to return to the dental office where she was previously seen due to behaviors related to obtaining local anesthesia during the last visit. The physician’s referral included an order for an external dental exam, Xrays and prophy (a routine preventative cleaning for healthy gums or gingivitis) at the nursing facility. The timeframe to complete the order was one week. The 1/15/26 social services progress note revealed Resident #30 was on the schedule to see the dentist on 1/6/26, however, Resident #30 was out of the facility so the appointment was to be rescheduled. -The appointment was scheduled for 1/6/26, 28 days after the physician referred Resident #30 to be seen by the facility dentist (see physician’s progress note above). The 2/10/26 dental emergency evaluation form revealed Resident #30 had pain on her upper right and lower right side of her mouth. The pain level was a 7 out of 10 and the pain had been present for seven days. There wereno antibiotics or pain medication prescribed. The 2/12/26 nurse note revealed Resident #30 was seen by the dentist in the morning for a recent complaint of pain in her gums and mouth. The dentist ordered oral antibiotics. The 2/13/26 nurse note revealed Resident #30 started her first dose of antibiotics and was compliant with the treatment. There were no side effects noted. The resident said she had pain on her gums that “goes on and off.” Resident #30 was on scheduled pain medication. The 2/18/26 social services note revealed Resident #30 was evaluated on an emergency basis due to dental pain. The dentist determined the affected tooth was infected and recommended extraction. Nursing reported Resident #30 recently completed a course of antibiotics for the infection and her pain was being managed. She was scheduled for an oral surgery consultation and treatment on 2/25/26 at 12:30 p.m. Social services director (SSD) #1 notified the physician of the upcoming appointment. Social services remained available for support and services as needed. -However, the social services note was completed one week after the dental emergency form was completed by nursing (see 2/10/26 dental emergency form above). The 2/19/26 social services note revealed Resident #30 had been on the dentist schedule for 2/9/26, however, the resident was not seen and would be rescheduled for the dentist’s next visit to the facility. -The appointment was scheduled on 2/9/26, 62 days after the physician referred Resident #30 to be seen by the facility dentist (see physician’s progress note above). The 2/22/26 at 12:43 p.m. nurse note revealed Resident #30 complained about pain around her right ear, below her right jaw and neck. There was no complaint of gum pain or oral pain. During the assessment, there was a complaint of swelling or redness on her gum or mouth. Resident #30 said the pain came with mild to moderate intensity. The physician was notified through the on-call nurse. Resident #30 was taking scheduled pain medications. Diclofenac gel applied to the affected pain area and the resident was waiting for a new order from the physician to treat the pain. The 2/22/26 at 6:01 p.m. nurse note revealed there was a faxed physician’s order received for naproxen (medication to treat pain) and the resident was notified of the new medication. IV. Staff interviews SSD #1, SSD #2, and the social services assistant (SSA) were interviewed together on 2/26/26 at 1:19 p.m. SSD #1 said when a resident requested dental services, social services sent a referral to the dentist after obtaining consent from the resident or responsible party. The SSA said the dentist provided social services with a list of residents to be seen at the next on-site dental visit. The SSA said the dentist came to the facility every other month. The SSA said residents were seen by the dentist annually or quarterly, depending on their insurance coverage. SSD #1 said if a resident had a specific dental need or emergency, the facility figured out a way for the resident to be seen by a dentist sooner, regardless of insurance coverage. SSD #1 said residents could be seen at the dentist’s next scheduled visit to the facility, unless the situation was considered an emergency. The SSA said the dentist provided the list of residents to be seen on the day of the visit to the facility and sometimes one week prior to their visit. The SSA said during the dentist’s February 2026 visit to the facility, the dentist did not see all residents on the list because he ran out of time. SSD #1 and the SSA said the dentist usually was able to see all of the residents who were scheduled to be seen. SSD #1 said if a resident complained of tooth pain, an emergency dental form was completed by the dentist. She said nursing was responsible for notifying the physician and the responsible party. SSD #1 said she used the emergency form to send to the dentist to schedule an appointment. SSD #1 said residents referred for oral surgery could usually be seen the same day. SSD #1 said she was familiar with Resident #30. She said she had received an email on 12/1/25 from the physician requesting a referral to the in-house dentist. SSD #1 said consent was obtained from Resident #30 and she was added to the next dentist visit to the facility. SSD #1 and the SSA said there needed to be better communication with the physician to confirm dental visits. SSD #1 said she did not know how the referral for Resident #30 had been made in December 2025 and did not know when Resident #30 was last seen by a dentist. SSD #1 said she was unaware the referral had been made to the facility dentist because Resident #30 had been discharged from the physician’s dental provider. SSD #1 was interviewed a second time on 2/26/26 at 4:17 p.m. SSD #1 said she contacted the oral surgeon’s office and learned Resident #30 did not attend her scheduled oral surgery appointment on 2/25/26. SSD #1 said she contacted the dental provider for clarification on why the resident was not seen for oral surgery on 2/25/26. She said the provider told her they told Resident #30 not to go to the appointment as the procedure would have resulted in an out of pocket expense for the resident and the dental provider did not contract with the oral surgeon. SSD #1 said the dental provider said the original referral to the oral surgeon was sent by the dentist before realizing the provider was not within their network. SSD #1 said the dental provider informed her of one contracted provider and they required a full set of dental Xrays before scheduling the procedure. SSD #1 said she followed up with Resident #30 to review the updated plan. She said Resident #30 told her she was contacted by her provider, understood the new plan and agreed to the new plan. SSD #1 said the resident reported no current oral discomfort and expressed she was comfortable waiting to schedule her oral surgery. SSD #1 said the dental provider said they planned to schedule Resident #30’s oral procedure in March 2026. -However, SSD #1 did not know the appointment was cancelled or why the appointment was cancelled until the first interview on 2/26/26 at 119 p.m. (see interview above). SSD #1 was interviewed on 2/26/26 at 4:17 p.m. SSD #1 said, based on the date the consent for dental services was signed by the resident in December 2025, Resident #30 should have been offered dental services sooner than what was offered.

Based on observations, record review and interviews, the facility failed to consistently serve food that was palatable in taste. Specifically, the facility failed to ensure resident food was palatable in taste and temperature. VI. Record review The recipe for the creamed spinach (see test tray observation above) was reviewed on 2/25/26 at 11:28 a.m. The creamed spinach indicated the ingredients included butter, flour, salt, nutmeg and spinach. The October 2025 food committee minutes revealed hamburgers were cooked differently with each cook and french fries needed to be cooked longer. The January 2026 resident council meeting minutes revealed residents wanted and agreed to discussing all dietary topics at the food committee meeting that followed right after resident council. One resident in particular had questions regarding menu, preferences and snacks. -However, a request for the January 2026 food committee meeting minutes revealed a food committee meeting did not take place in January 2026 (see NHA interview below). The February 2026 resident council meeting minutes revealed all residents were invited to attend the upcoming food committee meeting on 2/17/26. -However, a request for the February 2026 food committee meeting minutes revealed a food committee meeting did not take place in February 2026 (see NHA interview below). VII. Staff interviews Cook (CK) #1 was interviewed on 2/25/26 at 12:41 p.m. CK #1 said he did not have the ingredients on 2/25/26 to make creamed spinach, so the spinach was frozen spinach with nothing added to it. He said the rice was made with chicken broth, garlic and rice. -However, according to the recipe, CK #1 should have added butter, flour, salt and nutmeg into the creamed spinach. Certified nurse aide (CNA) #2 was interviewed on 2/25/26 at 4:51 p.m. CNA #2 said residents complained about how the food tasted. CNA #2 said she never offered to have the residents who complained fill out a grievance form because she tried to solve the problem in real time or told the nurse of their concerns. The NHA was interviewed on 2/26/25 at 5:26 p.m. The NHA said the facility did not have a dietary manager (DM). The NHA said she had an assistant DM and a registered dietitian (RD). The NHA said she lost her most recent DM the week prior to the survey (week of 2/16/26). The NHA said she knew there were resident concerns about how the food tasted. The NHA said she did not know the recipes were not followed by the dietary staff. The NHA said the gravy should not have tasted overly salty. The NHA said if the menu said creamed spinach and rice pilaf, the creamed spinach should have looked creamy and the rice pilaf should have revealed visible ingredients besides rice.

Based on observations, record review and interviews, the facility failed to ensure meals were served according to the resident’s preferences for one (#37) of five residents out of 41 sample residents. Specifically, the facility failed to offer food choices according to Resident #37’s preferences. Findings include: I. Facility policy and procedure The Resident Food Preferences policy, revised July 2017, was provided by the nursing home administrator (NHA) on 2/26/26 at 9:23 p.m. It read in pertinent part, “Staff will interview the resident directly to determine current food preferences based on history and life patterns related to food and mealtimes. Nursing staff will document the resident’s food and eating preferences in the care plan. The food services department will offer a variety of foods at each scheduled meal.” II. Resident #37A. Resident status Resident #37, age 69, was admitted on 9/28/25. According to the February 2026 computerized physician orders (CPO), diagnoses included chronic pain syndrome, malignant neoplasm of rectum and rectosigmoid junction (cancer located in the lower part of the large intestine where the colon meets the rectum), obesity, major depressive disorder, peripheral vascular disease (a circulatory condition that reduces blood flow to the arms or legs), chronic obstructive pulmonary disease, (COPD - a long-term lung disease that makes it difficult to breathe due to airflow blockage) unilateral inguinal hernia (a condition where tissue pushes through a weak spot in the abdominal muscles on one side of the groin), osteoarthritis, spinal stenosis (narrowing of the spaces within the spine), acute kidney failure, benign prostatic hyperplasia (BPH - noncancerous enlargement of the prostate gland that can cause urinary problems) and hypoxemia (lower than normal levels of oxygen in the blood). The 1/20/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. He was independent with eating, oral hygiene, toileting and personal hygiene. He required partial assistance with showering. B. Resident interview Resident #37 was interviewed on 2/23/26 at 3:23 p.m. Resident #37 said the facility did not give him the food he wanted for meals. He said for breakfast, he hated oatmeal and the facility always gave him oatmeal for breakfast. He said he wanted cold cereal and the facility never offered cold cereal. He said he hated turkey and they served him turkey. Resident #37 said the way the facility provided meals made him want to leave the facility because no one was listening to him. He said when the kitchen served him meals that he did not order, he would go without eating or he would leave the building to eat somewhere else. He said he talked to the male nurses in his unit about not receiving the food he wanted and the nurses said there was nothing they could do about it. C. ObservationsDuring a continuous breakfast observation on 2/24/26, beginning at 8:03 a.m. and ending at 8:30 a.m., Resident #37 was observed in the dining room. An unidentified staff member brought him breakfast. Resident #37’s breakfast consisted of pancakes, bacon and oatmeal. Resident #37 said he did not want oatmeal, however, the unidentified staff member did not offer the resident a replacement and left the oatmeal sitting on the dining room table. During a facility tour on 2/25/26 at 11:20 a.m., the meal menu, the alternative menu and the snack menu was observed in the elevator closest to the dining room and posted on a bulletin board in the main hallway near the lobby.-However, the menus posted did not have an alternative menu listed for breakfast. During a continuous observation on 2/25/26, beginning at 11:58 a.m. and ending at 1:30 p.m., the lunch preparation was observed in the main kitchen. Resident #37’s meal ticket did not reveal his dislike for turkey. He was served the posted lunch meal of braised turkey roast, rice pilaf, creamed spinach and spice cake. D. Record review The nutrition care plan, initiated and revised on 10/1/25, revealed Resident #37 was at potential nutrition and hydration risk due to a history of intussusception (a serious medical emergency where part of the intestine slides into another part, telescoping and causing a blockage), surgical aftercare following digestive surgery, absence of other specified parts of the digestive tract, hypoxemia, COPD, MDD, osteoarthritis, obesity, iron deficiency, anemia, hydronephrosis, hypercalcemia, acute kidney failure and neoplasm of the rectum. Interventions included providing and serving diet as ordered, administering medications as ordered, encouraging fluids as needed, encouraging healthy choices, inviting the resident to activities that involved food and fluids, monitoring for dysphagia and monitoring for malnutrition. -However, the care plan did not indicate Resident #37’s likes and dislikes. The 10/8/25 food preferences assessment documented that Resident #37 did not like turkey. The assessment said no turkey sandwiches or hot turkey. The 11/11/25 food preference assessment revealed he did not like turkey and cabbage. -However, Resident #37’s dietary meal ticket did not indicate the resident did not like turkey and observation during the survey revealed the resident received turkey roast for lunch on 2/25/26 (see observations above). III. Staff interviews Cook (CK) #1 was interviewed on 2/25/26 at 12:25 p.m. CK #1 said certified nurse aides (CNA) were responsible for completing the resident’s meal ticket on behalf of the resident. CK #1 said CNAs took lunch and dinner orders and residents were served whatever was on the breakfast menu for breakfast. CK #1 said the way a resident was served something different than what was on the breakfast menu was when the dietary manager (DM) updated the meal ticket with the resident’s preferred breakfast meal. CNA #2 was interviewed on 2/25/26 at 4:51 p.m. CNA #2 said the night shift CNAs were responsible for completing the resident’s meal ticket on behalf of the resident for the following day’s lunch and dinner meals. She said if the resident was not in their room when the night shift CNA asked residents what they wanted for lunch and dinner, the day shift CNA was responsible for completing the remaining incomplete tickets. She said breakfast meals were not ordered on behalf of the resident. CNA #2 said if the resident did not want what was on the menu, she was responsible for offering a substitution. She said sometimes residents did not like anything on the menu so she tried to offer what they wanted or asked the resident what they wanted to eat. CNA #2 said residents could change their mind and let the day CNA know by 10:00 a.m. She said if the resident changed their mind after 10:00 a.m. the resident had to tell the kitchen staff. CNA #2 said residents were served cold cereal based on their likes and dislikes. She said the cold cereal showed up on the breakfast meal ticket as a like. CNA #2 said there were residents who received hot cereal who did not like hot cereal. She said she tried to double check to make sure the residents received what they wanted. CNA #2 said she was familiar with Resident #37. She said he did not like turkey. She said he did not eat lunch (on 2/25/26) because he was served turkey. She said he was easily frustrated when he was not served what he preferred. CNA #2 said Resident #37 always asked for cold cereal. She said she had to remind the kitchen of his likes and dislikes because he was not always served cold cereal. The NHA was interviewed on 2/26/25 at 5:26 p.m. The NHA said the facility did not have a DM. The NHA said she had an assistant DM and a registered dietitian (RD). The NHA said she lost her most recent DM the week prior to the survey (week of 2/16/26). The NHA said the DM was responsible for completing the food preferences assessment for residents. The NHA said once the food preferences assessment was completed, theDM manually entered the likes and dislikes to the resident’s meal tickets. She said since she did not have a DM, the RD was responsible for completing the assessments and entering the likes and dislikes to the residents’ meal tickets. The NHA said breakfast orders were not taken for residents and if they wanted something different than what was on the menu, it would show up on their meal ticket as a like or dislike. The NHA said she was familiar with Resident #37 and she did not know his likes and dislikes. The NHA said she did not know Resident #37’s meal ticket did not match his likes and dislikes.

Based on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases. Specifically, the facility failed to ensure suction equipment was maintained in a sanitary manner. Findings include:I. Professional referenceAccording to the Healthcare Sterile Processing Association, August 2023, retrieved on 3/4/26 from https://myhspa.org/wp-content/uploads/2023/08/Fundamentals-of-sterile-storage.pdf,“Healthcare facilities must take action to create an environment that properly protects sterile packages. This includes securing a proper sterile storage environment and developing policies and procedures to help ensure sterile packages are safely stored and handled. If items are not properly protected or something unexpectedly happens, stored items may become contaminated. Providing the appropriate sterile storage environment and training personnel about proper handling and other essential sterile storage practices is critical for ensuring that the items remain sterile and ready for patient care.”II. ObservationOn 2/25/26 at 4:00 p.m. there was a Yankauer suction tip (a firm, plastic suction catheter designed to remove oral secretions) observed attached to the suction machine on the second floor crash cart. The Yankauer was not inside its sterile packaging. III. Staff interviewsLicensed practical nurse (LPN) #1 was interviewed on 2/25/26 at 4:00 p.m. LPN #1 said she did not know what to turn the suction machine to in an emergency. She said a Yankauer suction tip was not supposed to be attached to the suction machine, because the Yankauer should be stored in a sterile container and might accidentally be used. The assistant director of nursing (ADON) and the director of nursing (DON) were interviewed together on 2/26/26 at 4:50 p.m. The ADON said part of the night nurse’s duties when checking the crash carts was to check that the suction machine worked properly. The DON said while it might be considered best practice to have a Yankauer suction tip attached to the suction machine so it was readily available in an emergency, she did not think the Yankauer should be attached to the suction machine due to infection risk.

Based on observations and interviews, the facility failed to have an adequately equipped call system to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff area. Specifically, the facility failed to ensure all parts of the call light system were functioning properly in the common bathroom near the main dining room and the day room on the first floor. Findings include:I. Resident interviewResident #38 was interviewed on 2/23/26 at 1:00 p.m. Resident #38 said he was newly admitted to the facility and had gone to the bathroom in the common bathroom in the basement, near the dining room. He said he pulled the cord to call staff for help. He said the help never came as he waited for more than 20 minutes. Resident #38 said he used his cell phone and called a family member to ask for the facility to be called to come and help him. II. Observations and staff interviewOn 2/23/26 at 5:14 p.m. the bathroom call light was turned on in the common resident bathroom in the basement , next to the dining room. There was no call light above the door. There was a digitalized hanging monitor which displayed the room numbers when the call light was pulled. -However, the common bathroom did not display any notification when the call light in the bathroom was pulled. On 2/25/26 at 3:00 p.m. the lounge common area had a sign outside titled Day Room on the first floor. There were two residents sitting in the lounge watching television. The call light cord for the Day Room was clipped to the wall. -However, when the call light for the Day Room was pushed, it did not light up above the door outside the Day Room. Additionally, the big digitized hanging monitor which indicated which room the call lights were on was not displaying that the call light in the Day Room had been pushed. At 3:15 p.m. the call light was pushed a second time and the light above the door did light up. -However, the big digitized hanging monitor still did not display that the call light in the Day Room had been pushed. The computer at the nurses desk was logged out. Registered nurse (RN) #1 said the call lights which were pulled would register on the computer monitor, along with the big digitized sign. -However, RN #1 said she did not know how to log into the computer to visualize the rooms which had pulled the call light cords. III. Additional staff interviewsCertified nurse aide (CNA) #1 was interviewed on 2/23/26 at 5:33 p.m. CNA #1 said each floor had their own call light board to notify staff of call light activations. The nursing home administrator (NHA) was interviewed on 2/23/26 at 5:33 p.m. The NHA said the facility was not aware of the call light issue and was calling maintenance to look into the issue. She said the call light in the common area bathroom in the basement should have notified the staff on the first floor of the call light’s activation. The NHA was interviewed again on 2/23/26 at 5:37 p.m. The NHA said the call light in the common area bathroom near the dining room in the basement registered in the call light in the system and notified the staff at the nurses’ station, but not on the digitalized hanging monitor on the first or basement floors. She said she was closing the bathroom in the basement until maintenance resolved the issue. The maintenance director (MTD) was interviewed on 2/25/26 at 4:19 p.m. The MTD said the bathroom call light in the basement was fixed. He said it worked, however, it did not translate to the display board which was downstairs in the dining room. He said it also did not go upstairs, but he had fixed the problem. He said the call light now displayed on the big digitized board and on the computer.

Based on observations and interviews, the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public. Specifically, the facility failed to ensure necessary maintenance repairs were communicated and completed in a timely manner in the kitchen area. Findings include:I. ObservationsDuring a walkthrough of the kitchen on 2/25/26 from 11:28 a.m. to 11:53 a.m., the following was observed: -The wall behind the toaster was observed with visible burned marks. The wallpaper was observed peeling in multiple areas. There were sections of wallpaper observed missing above the toaster near the ceiling. -There were six holes observed in the wall to the right of the spice rack on the same wall as the toaster.-There were multiple areas of chipped paint observed on the ceiling along two pipes adjacent to the wall where the toaster was located. -There were multiple chipped paint marks observed on the ceiling along one pipe which was adjacent to the pipe line next to the wall where the toaster was located. -There were approximately twenty to thirty brown spots observed on the ceiling above the oven and stove. -The swamp cooler system located on the ceiling above the preparation table was observed with duct tape on one side. -The wall above and below the three-compartment sink was observed with multiple stains. At 11:33 a.m., the following was observed in the dishwasher room: -The vent to the right of the dishwasher was observed with an exposed sheetrock sheet measuring approximately six to eight inches in length.-There was a hole observed on the right side of the same vent. -There was missing tile observed on the wall and to the right of the dishwasher. -The vent above the dishwasher was observed with missing screws and was loose.-There were multiple areas of chipped paint marks observed above the sink. II. Staff interviews Cook (CK) #1 was interviewed on 2/25/26 at 11:50 a.m. CK #1 said if he needed anything repaired, he told the dietary manager (DM). He said he did not log if there were any repairs needed. CK #1 and dietary aide (DA) #2 were interviewed together on 2/26/26 at 4:00 p.m. CK #1 and DA #2 both said they did not know the last time the walls and ceiling in the kitchen were cleaned. DA #2 said he thought it was at least a month ago (January 2026), if not longer. The MTD was interviewed on 2/26/26 at 3:50 p.m. while touring the kitchen. The MTD said he had worked at the facility since October 2025. The MTD said he was responsible for the building’s maintenance. The MTD said he tracked maintenance requests using a software system. The MTD said each department’s management was responsible for informing him of maintenance requests in their departments. The MTD said there was not a dietary manager (DM) as of 2/20/26. The MTD said prior to 2/20/26, the DM did not inform him of any maintenance requests prior to leaving the facility. The MTD said the items identified on the kitchen tour, such as the holes in the wall, chipped paint and stains on the wall and ceilings, were not in his work order software system and they should be fixed.

Based on observations and interviews the facility failed to have adequate outside ventilation by means of a window or mechanical ventilation or a combination of the two for two out of three common bathrooms and two resident bathrooms, affecting eight residents. Specifically the facility failed to ensure the ventilation fans were clean and in good repair. Findings include:I. ObservationsOn 2/23/26 at 10:00 a.m. the 2nd floor was odorous. On 2/23/26 at 2:30 p.m. the shared bathroom in room #224 and room #223 had strong odors of a combination of urine and feces. There were no windows in the bathroom and the ventilation fan could not be heard. The ventilation fan cover had dust built up on it. The bathroom was shared by four residents. On 2/24/26 at 12:48 p.m. the shared bathroom in room #117 had strong odors of a combination of urine and feces. The ventilation fan cover had dust built up on it. The bathroom was shared by four residents. On 2/24/26 at 1:00 p.m. the shared bathroom in room #224 and room #223 continued to have strong odors of combination of urine and feces. On 2/24/26 at 1:30 p.m. the men’s public bathroom on the second floor had strong odors of a combination of urine and feces. There were not any windows in the bathroom and the ventilation fan could not be heard. On 2/24/26 at 1:33 p.m. the women’s public bathroom on the second floor had strong odors of a combination of urine and feces. There was a window in the bathroom; however, it was high up on the wall and blocked off by a bathtub with bars built up above the bathtub lip, which did not allow access to the window to open it. The ventilation fan could not be heard. On 2/25/26 at 2:30 p.m. the maintenance director (MTD) observed the men’s and women’s public bathrooms on the second floor and found that the ventilation fans were not working. The MTD observed room #224 and room #223’s shared bathroom and found that the ventilation fan was not working. The MTD observed that the ventilation fan cover in room #117 was dirty and the ventilation fan was not working properly. The ventilation fan was pulling in a little air, however, it was not working at full strength. II. Staff interviewThe MTD was interviewed on 2/25/26 at 2:30 p.m. The MTD confirmed the second floor had urine odors. He said the bathrooms all had individual ventilation fans. He said he checked the ventilation fans monthly. The MTD said the women’s public bathroom on the second floor had a window, however, he said he had to close the window up because when it was opened, it would make the hallway cold. The MTD said because the bathrooms did not have windows, the ventilation fans needed to work properly. He said he would get the ventilation fans replaced.

A survey with #CO2730150 was completed on 2/23/26 to 2/26/26. No deficiencies were cited.

A complaint survey, prompted by #CO2689968 was conducted on 12/29/25. No deficiencies were cited.

A survey for complaint #CO2689969 was completed on 12/29/25. No deficiencies were cited.

A complaint survey, prompted by #CO1943927, #CO1943930, #CO1943937, #CO2583793, Incident #1943934, Incident #2561198, Incident #2587392 and Incident #2587435 was conducted on 8/12/25 to 8/15/25. One deficiency was cited.

Based on observations, record review and interviews, the facility failed to ensure one (#1) of three residents reviewed for accidents received adequate supervision out of 14 sample residents. Specifically, the facility failed to ensure Resident #1 was not able to access hazardous chemicals. Resident #1, who was admitted to the facility on 4/9/07, had a history of dementia and of wandering within the facility. On 6/10/25 at 1:40 p.m., Resident #1 was able to obtain a bottle of a cleaning chemical that was located in a residential hallway on a maintenance cart that was unsecured and unsupervised. Resident #1 was found by certified nurse aide (CNA) #1 holding the bottle containing a cleaning chemical. Resident #1 was observed to have a blue substance on his lips, which was determined by the facility to be consistent with the contents of the bottle. Resident #1 was reported to have mouth and stomach pain after the incident. He was evaluated by a physician at the facility immediately following the incident and transferred to the hospital where additional evaluation was completed to determine if the resident had an esophageal (tube that runs from the throat to the stomach) injury, airway (breathing) compromise or electrolyte abnormality. Resident #1 was provided intravenous (IV) fluids and the hospital physician determined the resident likely had not ingested the toxic substance. Resident #1 was monitored at the hospital and returned to the nursing facility on 6/10/25. The facility determined the product in the bottle was a cleaning product (Gel Pro). The material safety data sheet (MSDS - a document that describes the hazards of a chemical product and provides information on safe handling, storage, disposal and emergency procedures) revealed the product was reserved for industrial and professional use and if swallowed, required immediate medical attention. Ingestion of the product could cause digestive tract burns. Resident #1 experienced pain and required hospital evaluation to confirm he had not ingested a sufficient amount of the chemical to cause further injury. The facility’s failure to ensure residents were not able to access hazardous chemicals placed Resident #1 and other residents at serious risk of harm, serious impairment or death if the situation were not corrected immediately. Findings include:Observations, record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 8/12/25 to 8/15/25, resulting in the deficiency being cited as past noncompliance with a correction date of 6/11/25. I. Situation of serious harmOn 6/10/25 at 1:40 p.m., Resident #1 was able to obtain a bottle of a cleaning chemical that was located in a residential hallway on a maintenance cart that was unsecured and unsupervised. Resident #1 was found by CNA #1 holding the bottle containing a cleaning chemical. Resident #1 was observed to have a blue substance on his lips, which was determined by the facility to be consistent with the contents of the bottleResident #1 was reported to have mouth and stomach pain after the incident. He was evaluated by a physician at the facility immediately following the incident and transferred to the hospital where additional evaluation was completed to determine if the resident had an esophageal injury, airway compromise or electrolyte abnormality. Resident #1 was provided IV fluids and the hospital physician determined the resident likely had not ingested the toxic substance. Resident #1 was monitored at the hospital and returned to the nursing facility on 6/10/25. II. Facility investigation and plan of correctionThe investigation and performance improvement plan (PIP) the facility implemented in response to the accident on 6/10/25 involving Resident #1 was provided by the nursing home administrator (NHA) on 8/13/25 at 1:07 p.m. The plan read as follows:A. Problem statementOn 6/10/25, a cognitively impaired resident (Resident #1) was found ingesting drain cleaner that had been left unattended and unsecured on a maintenance cart. CNA #1 intervened and removed the chemical. The chemical had been left unsecured by the maintenance supervisor during routine work. B. GoalThe facility’s goal was to eliminate unsafe chemical exposure risks within the facility by implementing a facility wide safety initiative with compliance monitoring and retraining all staff on accident prevention and emergency response protocols. C. Root Cause Analysis A root cause analysis (a problem solving method used to identify the underlying reasons why a problem occurred) was completed and revealed the following:-An unsecured hazardous chemical was left unattended in a resident accessible area;-Staff were unfamiliar with chemical handling/storage policies;-There was a lack of supervision or enforcement of the facility’s environmental safety procedures;-The cognitive impairment of the resident was not adequately considered in environmental planning; and,-There was not a current interdisciplinary team (IDT) environmental hazard audit process. D. Immediate Actions TakenCNA #1 immediately removed the chemical and reported the incident to the nurse. The nursing staff contacted a poison control center and reviewed the MSDS. The primary care physician (PCP) assessed the resident and Resident #1 was transported to the hospital. The maintenance supervisor was suspended from duties pending an internal review. The nursing home administrator (NHA) and the director of nursing (DON) initiated an internal investigation. E. Corrective actions and prevention planThe corrective actions included the following:An in-service on chemicals was completed on 6/10/25. A mandatory in-service for all departments on accident hazards was completed on 6/11/25. Hazard identification scenarios were integrated into training on 6/30/25. All maintenance carts were secured with locks or stored in secured areas when unattended by 6/11/25. The facility implemented facility-wide weekly environmental safety audits beginning 6/11/25. Accident prevention compliance checks were added to the monthly quality assurance performance improvement (QAPI) agenda beginning 6/30/25. Care plans for cognitively impaired residents were updated with supervision and safety risk protocols by 6/20/25. IV. Facility policy and procedureThe Hazardous Areas, Devices and Equipment policy, revised July 2017, was provided by the NHA on 8/14/25 at 3:22 p.m. It read in pertinent part, “A hazard is defined as anything in the environment that has the potential to cause injury or illness. Examples of environmental hazards include, but are not limited to:-Equipment and devices that are left unattended or are malfunctioning;-Devices and equipment that are improperly used or poorly maintained;-Sharp objects that are accessible to vulnerable residents;-Open areas or items that should be locked when not in use;-Irregular floor surfaces (cords, buckled carpeting, etc);-Objects in the hallways that obstruct a clear path;-Access to toxic chemicals;-Insufficient lighting or glare;-Unsafe exposure to heating elements or water temperatures;-Furniture that is unstable or positioned at an improper height for residents; or,-Disabled locks, latches or alarms.“Assessment and analysis of hazardous areas and equipment will include resident specific information including identification of vulnerable residents.“Any element of the resident environment that has the potential to cause injury and that is accessible to a vulnerable resident is considered hazardous.“Resident vulnerability is based on risk factors including the individual resident’s functional status, medical condition, cognitive abilities, mood, and health treatments (medications). “Interim safety measures for temporary hazards, such as painting or construction work, may be necessary. These may include posting warning signs, redirecting foot traffic, increasing supervision and if necessary, limiting access to anyone but authorized personnel.”V. Resident #1A.Resident statusResident #1, age 79, was admitted on 4/9/07. According to the June 2025 computerized physician orders (CPO), diagnoses included dementia, COPD, osteoarthritis, depressive episodes and anxiety disorder. The 5/7/25 minimum data sets (MDS) assessment revealed the resident had a severe cognitive impairment with a brief interview for mental status (BIMS) score of four out of 15. He required set up assistance with eating, substantial assistance with toileting, showering and dressing and was independent with the use of a manual wheelchair to wheel at least 150 feet in a corridor. B. Record reviewResident #1’s behavior care plan, revised 5/11/25, documented the resident self-propelled his wheelchair and enjoyed riding up and down in the main elevator. Interventions included redirection of Resident #1 as needed. Resident #1’s safety alert care plan, initiated 6/10/25, documented Resident #1 was at risk for injury due to his ingestion of non-edible or hazardous items related to his cognitive impairment, poor safety awareness and impaired judgment secondary to dementia. Interventions included environmental rounds conducted by staff every shift, documenting the resident’s attempts to access inappropriate items and ensuring all chemicals and hazardous materials were stored in locked non-resident areas. The primary care physician’s (PCP) progress note, dated 6/10/25 at 1:33 p.m., documented an urgent evaluation of Resident #1 for ingestion of drain cleaner. It documented the PCP evaluated the resident and remained with the resident until emergency medical services (EMS) arrived. It documented the amount of chemical ingested was not known, but the PCP estimated 10 milliliters (ml) had been ingested. The PCP documented Resident #1 was provided water to rinse with but he swallowed it. The PCP documented the resident was stable, but developed stomach pain immediately prior to the arrival of EMS. The note documented a poison control center was contacted and EMS was provided with a case number from the poison control center. The hospital emergency department progress note was provided by the NHA on 8/13/25 at 1:07 p.m. The note, dated 6/10/25 at 1:50 p.m., documented Resident #1 presented to the hospital for ingestion of a drain cleaning gel. It documented the EMS team reported the nursing facility staff said they witnessed Resident #1 taking a swig of the drain cleaning gel, but the facility was unsure how much was in the bottle before ingestion and unsure of the amount Resident #1 ingested. The EMS team also reported Resident #1’s mouth hurt, but otherwise he had no pain. The summary documented diagnoses considered were esophageal injury, airway compromise or electrolyte abnormality. The summary documented Resident #1 was stable and improved after IV fluids. The note documented the presentation and work up suggested Resident #1 had not ingested the toxic substance. A nursing progress note, dated 6/10/25 at 2:20 p.m., documented Resident #1 ingested drain cleaning gel on 6/10/25. It documented Resident #1 initially had no complaints of pain after the incident, but near time of EMS arrival to the facility, Resident #1 began to complain of abdominal pain. An in-service education, dated 6/10/25 was provided by the NHA on 8/13/25 at 1:07 p.m. The in-service education included 33 staff signatures. The training description included the process used if a resident ingested chemicals, poison control contact information and the location where the MSDS were kept. An in-service education, dated 6/11/25, was provided by the NHA on 8/13/25 at 1:07 p.m, and included 51 staff signatures. It documented the audience as all nursing, housekeeping, maintenance and support staff. The learning objectives included:-Identifying common environmental accident hazards and how to reduce resident risk;-Properly storing hazardous materials in compliance with federal and facility policy; and,-Understanding mandatory reporting obligations. The MSDS for the product Gel Pro was provided by the NHA on 8/13/25 at 1:07 p.m. It revealed the following:“Recommended use as a cleaning product reserved for industrial and professional use.“The product is corrosive to metals, causing severe burns and eye damage. “If swallowed, rinse the mouth. Do not induce vomiting. If inhaled, remove the person to fresh air and keep comfortable for breathing. Immediately call a poison center/doctor. “Store locked up. Store in corrosive resistant container with a resistant liner“Ingredients include sodium chloride, sodium hypochlorite and sodium carbonate.“First aid measures include if swallowed, rinse mouth with water, do not induce vomiting. Get medical attention immediately.“Note to physician, treat symptomatically.“Handling and storage, do not ingest. “If ingested, it causes digestive tract burns.”Facility-wide weekly environmental safety audits were provided by the NHA on 8/13/25 at 1:07 p.m. Weekly audits from 6/11/25 to 8/6/25 were reviewed. The audits documented all chemicals on carts were secured or locked if unattended, storage rooms with hazardous materials were locked, MSDS were visible and accessible, chemicals were clearly labeled and not expired and high risk resident areas were free of hazards. VI. Staff interviewsCNA #3 was interviewed on 8/13/25 at 12:50 p.m. CNA #3 said Resident #1 had a history of wandering on the unit in his wheelchair. CNA #1 said there was an incident when Resident #1 drank something from the maintenance cart. He said all of the facility staff received training, both online and in person about hazardous materials and the importance of securing the items. CNA #3 said he was told to report any observations of hazardous materials at the facility. The DON was interviewed on 8/13/25 at 4:00 p.m. The DON said she was present at the facility and responded to Resident #1’s room after the incident on 6/10/25. She said she learned Resident #1 might have put the bottle of drain cleaner in his mouth. The DON said Resident #1 had a blue substance around his mouth from the chemical. The DON said the facility was inspected for hazardous materials on that day and she participated in providing staff education for hazardous materials after the incident. The maintenance supervisor was interviewed on 8/14/25 at 8:50 a.m. The maintenance supervisor said on 6/10/25, he and his assistant were painting the day room, a resident lounge. The maintenance supervisor said he had painting supplies on the maintenance cart, and there was also a bottle of drain cleaner, as he planned to clean a drain in the facility’s kitchen area after he completed painting. The maintenance supervisor why she was holding the bottle and she said Resident #1 drank from it. The maintenance supervisor said he contacted the PCP, who was present at the facility, and then obtained the MSDS for the drain cleaner. The maintenance supervisor said he observed Resident #1 with a blue color present on his lower lip which was consistent with the contents of the drain cleaner. The maintenance supervisor said after the incident, the facility ensured there were not any chemicals which were accessible to residents. The maintenance supervisor said he received training upon hire about hazardous chemicals and the need to ensure they were not accessible to residents, and again received training from the NHA after the incident on 6/10/25. The maintenance supervisor said the facility purchased new maintenance carts in June 2025 which were always locked. The NHA was interviewed on 8/14/25 at 9:04 a.m. The NHA said the maintenance cart should have been secured and the items on the cart should not have been accessible to residents on 6/10/25. The NHA said the facility completed an audit on the day of the incident to be certain there were no accessible hazardous materials. She said staff training began immediately after the incident, and the training was completed by 6/11/25. The NHA said weekly audits for environmental and hazardous items would continue for at least three months and would be reviewed at QAPI meetings. Registered nurse (RN) #2 was interviewed on 8/14/25 at 9:50 a.m. RN #2 said CNA #1 came to her holding a drain cleaner bottle and informed her she had just taken bottle from Resident #1. RN #2 said she went to the resident and saw that he had a blue color on his lips. RN #2 said the instructions on the bottle revealed his mouth should be rinsed out, so she and CNA #1 attempted to do this, but Resident #1 swallowed the water. RN #2 said the PCP was at the facility and came to the resident’s bedside immediately. RN #2 said while waiting for the EMS team to arrive, Resident #1 said he had started to have stomach pain. RN #2 said she contacted Resident #1’s representative about the incident and transfer to the hospital. RN #2 said all facility staff received re-education about hazardous items after the incident. RN #2 said the staff audited the building to be certain there were no hazardous items accessible to residents. The PCP was interviewed on 8/14/25 at 12:15 p.m. The PCP said on 6/10/25, a staff member notified him that Resident #1 had consumed drain cleaner. The PCP said he reviewed the MSDS for the product and contacted a poison control center. The PCP said he was told the resident had blue color on his lips, and he estimated the resident drank approximately 10 ml of the drain cleaner, based upon staff reports and the amount remaining in the bottle. The PCP said Resident #1 appeared stable, but was sent to the hospital out of an abundance of caution, as he began to have abdominal pain. The PCP said the facility did a PIP related to the incident and addressed the cause of the ingestion. He said if Resident #1 had ingested more drain cleaner “he would have been in trouble,” as it could have caused a hole through his esophagus or his stomach. CNA #1 was interviewed on 8/14/25 at 12:45 p.m. CNA #1 said on 6/10/25, she saw Resident #1 sitting in his wheelchair in the hallway drinking from a bottle that contained a chemical. CNA #1 said she took the bottle away from the resident. CNA #1 said she realized Resident #1 had drank some of the chemical when she noticed his lips and tongue were blue. She said she notified the charge nurse, and the charge nurse and PCP evaluated the resident. CNA #1 said the facility had all staff check the facility, including all residents’ rooms for hazardous items, including chemicals, following the incident on 6/10/25. CNA #1 said the facility provided inservice training after the incident for all staff, which included both in person and online training and included the need to ensure residents could not access hazardous items. The social services director (SSD) was interviewed on 8/15/25 at 9:30 a.m. The SSD said she received hazardous material training upon hire and again recently completed training in person and online after the incident involving Resident #1. The SSD said the training focused on the need to protect residents from hazardous items. The SSD said she was one of the staff members who were doing weekly rounds to check for any hazardous items. She said the extensive training post-incident for all staff helped to make the staff sensitive to the potential hazards that existed to residents.

A survey for Incident #38685, Incident #38999, Incident #39209 and Incident #39210 was conducted on 3/3/25 to 3/4/25. No deficiencies were cited.

A document revisit was completed with all deficiencies being corrected. No other deficiencies were cited and no response is needed.

A revisit survey was completed on 5/7/24 for all previous deficiencies cited on 2/27/24. The facility is in compliance with all regulations surveyed.

INITIAL COMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility's general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a). The facility is two story, Type V (111), construction. The facility is protected throughout by National Fire Protection Association (NFPA) 13 automatic fire suppression systems and is classified as Fully Sprinklered. The facility was constructed in the early 1900's to 1973 and is license for 68 beds. This re-certification survey conducted on March 20, 2024 for compliance with the National Fire Protection Association, (NFPA 101) Life Safety Code (2012) "Chapter 19, Existing Health Care Occupancies". The deficiencies cited were discussed with the Director of Plant Operations during the survey any again during the exit conference.

Based on a record review it was determined that the facility failed to maintain the fire alarm system components and devices in accordance with the Life Safety Code Section 9.6 and NFPA 72.1. 2 year smoke detector sensitivity report not available for reviewNFPA 101, Section 9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code. NFPA 72- 14.4.2.2* Systems and associated equipment shall be tested according to Table 14.4.2.2. (15). Alarm notification appliances (a) Audible: Test shall be performed in accordance with the manufacturer ' s published instructions. Appliance locations shall be verified to be per approved layout, and it shall be confirmed that no floor plan changes affect the approved layout. It shall be verified that the candela rating marking agrees with the approved drawing. It shall be confirmed that each appliance flashes. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the maintenance director at the exit conference.

Based on observations and records review, it was determined that the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association NFPA 25 and NFPA 1011. Multiple Fire Sprinkler head with paint in facility main corridor all wall sprinkler headsNFPA 25 5.2.1.1.2 Any sprinkler that shows signs of any of the following shall be replaced: (1) Leakage, (2) Corrosion, (3) Physical damage, (4) Loss of fluid in the glass bulb heat responsive element, (5)* Loading (6) Painting unless painted by the sprinkler manufacturer. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the maintenance director at the exit conference.

Based on observation it was determined the facility failed to maintain corridor doors in accordance with NFPA 101.1. Cover need to be replaced on fire door closing appliance | first floor corridor 2. Black Gate needs to be removed for nurses station 3. Roll down fire door for kitchen need to be inspected | All though this door is not in use the fire protection feature have to be maintainedNFPA 80 5.2.1* Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ.NFPA 101, 19.3.6.3.1* Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be doors constructed to resist the passage of smoke and shall be constructed of materials such as the following:(1) 13/4 in. (44 mm) thick, solid-bonded core wood(2) Material that resists fire for a minimum of 20 minutesNFPA 101, 19.3.6.3.5* Doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction, and the following requirements also shall apply:(1) The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door.(2)Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.7. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the maintenance director at the exit conference.

Based on observation and staff interview during the course of the survey it was determined the facility failed to maintain smoke barriers in accordance with NFPA 101, 8.5.1. This was evidenced by the following:1. Electrical room penetrations in ceiling need to be filledNFPA 101, Section 8.5.1, in part, smoke barriers shall be provided to subdivide building spaces for the purpose of restricting the movement of smoke. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the maintenance director at the exit conference.

Based on observation and staff interview, it was determined that the facility failed to maintain wiring in accordance with NFPA 101 and NFPA 70.1. Dryer orifice need to switched out for high altitude orifices 2. Air conditioner plugged into surge protector room 225NFPA 101, 9.1.1 Gas. Equipment using gas and related gas piping shall be in accordance with NFPA 54, National Fuel Gas Code. NFPA 54, 11.1.2 High Altitude. Gas input ratings of appliances shall be used for elevations up to 2000 ft (600 m). The input ratings of appliances operating at elevations above 2000 ft (600 m) shall be reduced in accordance with one of the following methods:(1) At the rate of 4 percent for each 1000 ft (300 m) above sea level before selecting appropriately sized appliance(2) As permitted by the authority having jurisdiction.(3) In accordance with the manufacturer ' s installation instructions. NFPA 101 9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the maintenance director at the exit conference.

Based on observation and staff interview, it was determined that the facility failed to maintain smoke dampers in accordance with Life Safety Code Section NFPA 1051. Damper report does not include inspection information for each individual damper in facility NFPA 105, 6.5.1 Smoke dampers for dedicated and non-dedicated smoke control systems shall be inspected and tested in accordance with NFPA 92A, Standard for Smoke-Control Systems Utilizing Barriers and Pressure Differences. 6.5.2* Each damper shall be tested and inspected one year after installation. The test and inspection frequency shall then be every 4 years, except in hospitals, where the frequency shallbe every 6 years. 6.5.3 Care shall be exercised that all tests are completed in a safe manner wearing the appropriate personal protective equipment. 6.5.4 Full unobstructed access to the damper shall be verified and corrected as required. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the maintenance director at the exit conference.

Based on record review, it was determined that the facility failed to conduct fire drills in accordance with the Life Safety Code, Section 19.7.1.61. All Fire Drills in the 4th Quarter 2023 recorded as PM drills | No AM drills NFPA 101, 19.7.1.6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the maintenance director at the exit conference.

Based on documentation review, it was determined that the facility did not maintain proper electrical practices in accordance with NFPA 99 Health Care Facilities Code (2012). This was evidenced by:1. No current written record of the continuity of the grounding circuit, polarity of hot and neutral connections, and retention force of the grounding blade in patient care rooms was conducted annually. NFPA Standard: NFPA 99 Health Care Facilities Code (2012)6.3.3.2 Receptacle Testing in Patient Care Rooms. 6.3.3.2.1 The physical integrity of each receptacle shall be confirmed by visual inspection. 6.3.3.2.2 The continuity of the grounding circuit in each electrical receptacle shall be verified. 6.3.3.2.3 Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed. 6.3.3.2.4 The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz). This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the maintenance director at the exit conference.

Based on observation and record review during the survey, it was determined that the facility failed to maintain the back-up emergency generator in accordance with National Fire Protection Association (NFPA) Standard 110. This was evidence by the following: 1. Annual load bank test not NFPA 110 complaint 8.1.1 The routine Maintenance and operational testing program shall be based on all of the following: Manufacturers recommendationsInstruction manualsMinimum requirements of this chapterThe authority having jurisdiction This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the maintenance director at the exit conference.