**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 21 residents. The sample included 12 residents with one resident reviewed for hospitalization. Based on interview and record review, the facility failed to provide Resident (R) 5 a written notification of transfer to the resident and/or his representative as soon as practicable. This placed the resident at risk of impaired rights related to transfer and discharge. Findings included:- R5's Electronic Medical Record (EMR) revealed a diagnosis of heart failure (a condition where the heart muscle is weakened and cannot pump blood effectively enough to meet the body's needs).R5's EMR documented a Progress Note which noted R5 transferred to the hospital on [DATE].R5's EMR lacked documentation of a written notification to the resident and/or his representative, which explained the reason for the transfer to the hospital.On 09/04/25 at 07:55 AM, Social Services Staff X stated the family was provided the bed hold policy, and the Ombudsman was notified of the transfer to the hospital. Social Services Staff X confirmed that staff had not notified the resident and/or his representative in writing of the reason for transfer to the hospital. On 09/04/25 at 11:15 AM, Administrative Nurse D said she was unaware of the requirement to notify the resident and/or his representative in writing of the reason for transfer to the hospital, and confirmed that it was not done for R5's transfer on 07/14/25.The facility policy for Transfer Agreement, last reviewed 12/02/24, included: Before the facility transfers or discharges a resident, the facility shall notify the resident and the resident's representative of the transfer or discharge.

The facility reported a census of 21 residents, and one main kitchen. Based on observation, record review, and interview, the facility failed to prepare and serve food under sanitary conditions to prevent the potential for food borne bacteria. This placed the residents at risk for food borne illnesses. Findings included:- During the initial tour of the kitchen on 09/02/25 at 08:40 AM, observation revealed a bag of beef patties, a bag of hash browns, one bag of fish, and one bag of chicken strips were left open to air. Three cutting boards had a black substance around the edges and grooves in the boards.The pans and bowls were not inverted or covered. On 09/04/25 at 11:05 AM, the follow-up kitchen tour revealed a box of beef patties left open in the freezer area, and the cutting boards still had the black substance around the edges of the cutting boards and deep grooves. On 09/02/25 at 11:25 AM, Dietary Staff BB revealed that the staff were reminded to close the bags and to date when the bag was opened. Dietary Staff BB said the cutting boards will be replaced. The policy Food and Nutrition-Food Preparation-Manor and Hospital, dated 06/24/25, documented that all dietary personnel and other persons preparing food for the consumption of residents shall be routinely instructed and evaluated in sanitary food handling techniques, hand washing practice, and personal hygiene.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 26 residents, which included 12 residents, that included one resident reviewed for accommodation of needs. Based on observation, record review, and interview, the facility failed to provide reasonable accommodations related to an appropriately sized mechanical lift sling for Resident (R)4. Findings included: - The Electronic Health Records (EHR) for Resident (R)4 included diagnoses of diabetes mellitus type 2 (DM2 - when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), chronic pulmonary edema (a chronic condition in which the lungs accumulate excess extravascular fluid around the lung tissue) and generalized weakness. The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R4 required extensive assistance from two staff for all cares except eating and received hospice services. The ADL (activities of daily living such as walking, grooming, toileting, dressing and eating) Functional / Rehabilitation Potential Care Area Assessment (CAA) dated 10/09/23, documented R4 had an ADL self-care deficit related to multiple diagnoses which included (but not limited to) generalized weakness, non-ambulatory (not walking) status, limited range of motion due to body size and chronic pain. The Care Plan dated 01/03/24, documented R4 had an ADL self-performance deficit and instructed staff to utilize a Hoyer lift (a two-person full-body mechanical lift use to transfer residents) and lacked direction on the size of sling to use. The Physician Orders lacked information related to the full body mechanical lift use. On 01/02/24 at 11:21 AM, R4 revealed that the full body mechanical lift sling that staff had been using caused discomfort during transfers because it was too small for his body. On 01/03/24 at 07:25 AM, Certified Nurse Aide (CNA)C, CNA F and CNA E transferred R4 with a full body mechanical lift. R4 expressed discomfort due to the sling size during the transfer. On 01/04/24 at 09:49 AM, CNA C stated that the Hoyer lift was a little too small for the resident to use and the legs of the mechanical lift could not open wide enough to accommodate R4's wheelchair. Additionally, stated that R4 was recently readmitted to the facility on hospice and that hospice provided the lift and that even though the lift and sling are too small for the resident, staff were to use the hospice lift and not the two lifts owned by the facility. Further stated that R4 used to complain daily about the lift causing discomfort but has given up on saying anything about it. On 01/04/24 at 10:01 AM, CNA D confirmed that R4 was readmitted to the facility on hospice services and that the lift provided by hospice was too small for R4. The facility owned lifts that were larger, but staff were to use the lift provided by hospice even if it was too small because the hospice lift was in the room and the other ones were stored all the way at the end of the hall. On 01/04/24 at 10:23 AM, Administrative Nurse B confirmed that R4 had recently readmitted to the facility on hospice services; however, stated that staff had not been advised to exclusively use the lift provided by hospice rather than the two larger lifts owned by the facility. Administrative Nurse B was not aware R4 expressed discomfort related to the small size of the full body mechanical sling. Stated that her expectation was for staff to utilize appropriately sized equipment to accommodate R4's body size without causing discomfort. The facility's Accommodation of Need policy, dated 02/2004, documented that residents have the right to reside and receive services with reasonable accommodations of individual needs. The facility failed to provide this resident with reasonable accommodations of his needs and preferences for an appropriately sized mechanical lift sling.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 26 residents with 12 residents selected for review which included three residents reviewed for accident hazards. Based on observation, interview, and record review, the facility failed to provide a safe environment when staff failed to carry call light pagers hooked to the call light system to alert staff when the resident moved. Resident (R) 25 had a fall with minor injury and staff were unaware the alarm sounded to his movements prior to a fall. Findings include: - R25's Electronic Health Record (EHR) revealed the resident had diagnoses that included dementia (a progressive mental disorder characterized by failing memory, confusion) and benign prostatic hyperplasia (BPH - a non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency, and urinary tract infections). The admission Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of two, indicating severely impaired cognition. The resident required moderate assistance of staff for all cares, except eating. The resident utilized a walker or wheelchair for locomotion. The Cognitive Loss / Dementia Care Area Assessment (CAA) dated 10/12/23, documented the resident had impaired cognitive function and short-term memory loss related to dementia. The Falls CAA, dated 10/12/23, documented that the resident was at a moderate risk of falls related to confusion, lack of safety awareness, incontinence, and generalized weakness. The Care Plan dated 01/03/24, documented R25 was at moderate risk for falls and instructed staff to perform the following interventions: 1. On 10/04/23, instructed staff to anticipate and meet R25's needs. 2. On 10/04/23, instructed staff to ensure the call light was within reach and encourage the resident to use it for assistance. (With severely impaired cognition, this is ineffective as the resident would not remember.) 3. On 10/04/23, instructed staff to ensure the resident was wearing appropriate footwear when transferring and ambulating. 4. On 10/04/23 and revised on 11/01/23, instructed staff that the resident ambulated with a gait belt and walker. Staff were to pull the wheelchair behind the resident. 5. On 10/04/23, instructed staff to place a silent fall alarm on the resident's recliner and bed. (A type of alarm hooked to the call light system to alert staff of resident movements.) 6. On 11/21/23, instructed night shift nurses to carry call light pagers to help respond to the silent fall alarms in a timelier manner. The Fall Risk Assessments documented the following: 1. On 10/03/23, fall risk score of 14, which indicated the resident was at risk for falls. 2. On 11/21/23, fall risk score of 11, which indicated the resident was at risk for falls. Review of fall reports revealed that on 11/21/23 at 05:40 AM, R25 had a fall with minor injury. The root cause analysis investigation determined that the staff did not respond to R25's fall alarm in an adequate time to prevent the fall because they failed to carry the call light pagers with them. On 01/04/24 at 10:23 AM, Administrative Nurse B revealed her expectation was for all licensed nursing staff to carry the call light pagers to assist in answering call lights when the Certified Nurse Aides (CNAs) were busy with other call lights. Administrative Nurse B further explained that on the night of 11/21/23 when R25 fell, the nurse on duty was not wearing the call light pager as per her expectation. The facility's Fall and Accident Prevention Policy policy, dated 08/28/20, documented that the facility would provide an environment that was free from accident hazards that the facility had control, which included supervision and assistance to prevent avoidable accidents. The facility failed to provide a safe environment when staff failed to follow care planned interventions including to carry the call light pagers on the night shift when R25 had a fall with minor injury and staff were unaware he had called for help. - R10's Electronic Health Record (EHR) revealed the resident had diagnoses that included dementia (a progressive mental disorder characterized by failing memory, confusion) and major depressive disorder (a mood disorder categorized as mental health problems, feelings of sadness, helplessness, guilt, wanting to die were more intense and persistent than what may normally be felt from time to time). The 11/10/23 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of three, which indicated severely impaired cognition. The resident was dependent on staff for cares. The 11/10/23 Cognitive Loss / Dementia Care Area Assessment CAA, documented that the resident had impaired cognitive function with cognitive decline noted related to her diagnosis of dementia. R10 had chronic episodes of inattention, disorganized thinking, and the appearance of decreased consciousness where she was less responsive to others around her. The 11/10/23 Falls CAA, documented R10 was at risk for falls related to weakness, dementia, medications, aggressive behaviors at times during ADLs (activities of daily living - such as grooming, walking, bathing, and toileting), and had a history of falls. Soft touch call light in place. Directed staff to anticipate and meet R10's needs as she was unable to make them known verbally and that a dycem (a slip resistant pad placed between the buttocks and a chair) pad was to be placed on top of R10's wheelchair cushion to prevent buttocks from sliding forward for fall prevention. The Care Plan, dated 11/16/23, documented that R10 was a moderate risk for falls and instructed staff to perform the following interventions: 1. On 06/08/18, for staff to anticipate and meet R10's needs as she was unable to make them known verbally. 2. On 11/14/2023, for staff to place dycem on top of the wheelchair cushion to prevent buttocks from sliding forward for fall prevention. 3. On 05/26/2021, for staff to ensure that R10 wore appropriate footwear such as non-skid socks, shoes, when ambulating and must have one to two staff assisting with ambulation. R10's primary mode of locomotion was for staff to propel R10's wheelchair, but R10 would sometimes propel herself. 4. On 11/22/2022, that R10 didn't use her call light but instructed staff to make sure R10's call light was within her reach for use by utilization of soft touch call light. 5. On 06/18/18, R10 needed a safe environment with: even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in a position that best fits her height; handrails on wall in bathroom and personal items within reach. 6. On 12/31/23, instructed a staff member to face R10 and to maintain visual supervision while resident is using the restroom. 7. On 12/09/23, instructed staff to perform visual safety checks every 15 minutes while awake. The Physician's Orders lacked orders specific to fall prevention. The EHR Assessments documented the following: 1. On 12/09/23, fall risk evaluation of 12, which indicated resident was at risk for falls. 2. On 12/31/23, fall risk evaluation of 12, which indicated resident was at risk for falls. The facility fall report revealed R 10 had an unwitnessed fall on 10/9/2023 with no injury and a witnessed fall on 12/31/23 that resulted in a hematoma (collection of blood trapped in the tissues of the skin or in an organ, resulting from trauma) to her forehead. On 01/03/23 at 08:30 AM, R10's wheelchair lacked a dycem pad. On 01/04/03 at 07:45 AM, Certified Nurse Aide (CNA) G reported that if staff do not look at the resident [NAME] (nursing tool that gives a brief overview of the care needs of each resident) each day, they would likely not know that a dycem pad should be in R10's wheelchair. On 01/03/23 at 11:27 AM, Administrative Nurse B revealed that R10 should have dycem pad in her wheelchair per the instructions in the care plan to reduce the risk of falls from R10 sliding out of her wheelchair. The facility's Fall and Accident Prevention Policy policy, dated 08/28/20, documented that the facility would provide an environment that was free from accident hazards that the facility had control, which included supervision and assistance to prevent avoidable accidents. The facility failed to provide a safe environment when staff did not ensure that a dycem pad in R10's wheelchair as documented in the care plan. This deficient practice created an accident hazard related to falls.

The facility reported a census of 26 residents. Based on interview and record review, the facility failed to submit complete and accurate staffing information to the Federal regulatory agency through Payroll-Based Journaling (PBJ) when the facility failed to accurately submit hourly staffing data for all nursing personnel. Findings included: - Review of the Fiscal Year (FY) Quarter 1, 2023 (October 1 - December 31), the facility failed to accurately submit the Licensed Nursing Coverage 24 hours/Day for the following dates: 10/01 Saturday (SA); 10/02 Sunday (SU); 10/08 (SA); 10/09 (SU); 10/15 (SA); 10/22 (SA); 10/23 (SU); 10/27 Thursday (TH), 11/05 (SA); 11/29 Tuesday (TU);12/12 Monday (MO), and 12/16 Friday (FR). FY Quarter 2, 2023 (January 1 - March 31), the facility failed to accurately submit the Licensed Nursing Coverage 24 hours/Day for the following dates: 01/18 Wednesday (WE); 02/18 (SA); 02/26 (SU); 03/11 (SA); 03/12 (SU); 03/18 (SA) and 03/26 (SU). FY Quarter 3, 2023 (April 1 - June 30), the facility failed to accurately submit the Licensed Nursing Coverage 24 hours/Day for the following dates: 04/29 (SA); 04/30 (SU); 05/02 (TU); 05/06 (SA); 05/27 (SA); 05/28 (SU); 06/17 (SA); 06/24 (SA); and 06/25 (SU). Review of the nursing schedule and clocking sheets for the above dates revealed adequate hours to account for 24-hour nursing coverage. Interview on 01/04/24 at 12:30 PM, Administrative Nurse B reported that Human Resource staff (HR) at the hospital was responsible for submission of payroll data and was unable to provide explanation for inaccurate data. The Electronic Staffing Data Submission Payroll-Based Journal for Long Term Care Facilities, dated 06/2022, documented that long term care facilities must electronically submit to Centers for Medicare Services (CMS - the federal regulatory agency) complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable date in a uniform format according to specifications established by CMS. The facility failed to submit complete and accurate staffing information to the Federal regulatory agency through PBJ when the facility failed to accurately submit hourly staffing data for all nursing personnel.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility census totaled 19 residents with eight residents included in the sample. Based on observation, interview, and record review the facility failed to provide written notice to the State Ombudsman of the 12/13/21 facility-initiated hospitalization transfer of Resident (R) 9. Findings included: - R9's Electronic Health Record (EHR) documented diagnoses of muscle spasm of back, and chronic pain. The 10/13/21 admission Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The 01/06/22 Quarterly MDS revealed a BIMS score of 15, which indicated intact cognition. The 12/13/21 Health Status Note documented R9 stated her pain was unbearable and that she would like to be transported to the emergency room. Observation on 02/16/22 at 09:44 AM revealed R9 sat in a recliner in her room, was pleasant, had a smile on her face and did not appear to be in any pain. On 02/16/22 at 11:59 AM, Social Services Designee (SSD) D stated she notified the ombudsman of any residents discharged to the hospital at the beginning of each month. SSD D stated she could not find this notification concerning R9's 12/13/21 hospitalization. On 02/16/22 at 12:16 PM, Administrative Nurse B stated it was her understanding the Social Services Designee (SSD) was the one who notified the ombudsman when a resident was transferred to the hospital. The facility did not provide a policy on ombudsman notification of resident transfer to the hospital. The facility failed to notify the ombudsman when R9 admitted to the hospital on [DATE].

The facility census totaled 19 residents with eight residents included in the sample. Based on observation, interview, and record review the facility failed to provide Resident (R) 9 or her representative with a bed hold policy upon transfer to the hospital. Findings included: - R9's Electronic Health Record (EHR) documented diagnoses of muscle spasm of back, and chronic pain. The 10/13/21 admission Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The 01/06/22 Quarterly MDS revealed a BIMS score of 15, which indicated intact cognition. The 12/13/21 Health Status Note documented R9 stated her pain was unbearable and that she would like to be transported to the emergency room. Observation on 02/16/22 at 09:44 AM revealed R9 sat in a recliner in her room, was pleasant, had a smile on her face and did not appear to be in any pain. On 02/16/22 at 11:49 AM, Licensed Nurse (LN) C stated R9 was sent to the hospital due to having had bad back pain. LN C stated there was a bed hold included in a hospital transfer packet that was provided at the time of transfer to the hospital, but was not signed by either R9 or her representative. On 02/16/22 at 12:16 PM, Administrative Nurse B stated the nurse should provide the bed hold policy upon transfer, but stated there was no current system to make bed holds were signed by the resident or their representative. The facility's Bed Hold Policy & Resident Return policy dated 02/07/22 documented, At the time a resident is transferred to a hospital .the resident/resident representative will be provided with, and asked to sign, a request for bed hold form. The facility failed to provide R9 or her representative with written notice concerning the facility's bed hold policy when R9 discharged to the hospital.

The facility had a census of 19 residents with 8 residents in the sample. Based on observation, interview, and record review the facility failed to perform blood sugar testing on two residents, Residents (R) 12 and R5 in a sanitary manner when Licensed Nurse (LN) C failed to clean the facility glucometer (instrument used to calculate blood glucose) after using it on the first resident and/or before testing the second resident. Findings included: Observation on 02/16/22 at 08:14 AM revealed LNC as she checked the blood sugar for R12. The nurse donned gloves and cleaned R12's finger with an alcohol pad. LN C then used a lancet (sharp object to pierce skin to obtain blood sample) to draw blood and placed a small drop of blood onto the glucometer strip. LN C then left the glucometer sitting on the counter and failed to clean it after use. Observation on 02/16/22 at 08:23 AM revealed LN C as she checked the blood sugar for R5. The nurse donned gloves and used an alcohol pad to clean R5's finger. Using a lancet to draw R5's blood, she then placed it on the strip in the uncleaned glucometer, which she previously used on R12. LN C then placed the glucometer in the top drawer of the medication cart without cleaning it after using it for both R12 and R5. On 02/16/22 at 08:30 AM LN C reported she probably should have cleaned the glucometer and took it back out of the cart. The nurse then put gloves on and cleaned it with a wet disinfecting wipe. On 02/16/22 at 09:45 AM Administrative Nurse B reported the glucometer should be cleaned after every use. She was of the understanding all residents receiving blood sugar checks had their own glucometer in the medication cart. The facility policy named Blood Glucose Monitoring dated 12/2016 revealed the licensed nurse would test a resident's blood sugar level with the facility provided glucometer. After each resident use, the glucose monitoring device would be thoroughly cleaned. The device would then be placed in a zip-loc bag labeled with that resident's name when appropriate. The facility failed to perform blood sugar testing on two residents in a sanitary manner by the failure to clean the facility glucometer after using it and before testing a second resident.