**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility's policy, the facility failed to report misappropriation within 24 hours for 1 of 2 sampled residents investigated for misappropriation, Resident (R) 74.It was reported on 11/09/2024 at 7:05 PM per e-mail to the Director of Nursing (DON) and the Administrator that R74 reported missing money from his wallet. However, the Administrator did not report the incident to the required entities until 11/11/2024. The findings include:Review of the facility's policy titled, Allegations of Abuse/Neglect, effective date 06/11/2025, revealed all alleged incidents involving mistreatment, neglect, or abuse including injuries of unknown origin and misappropriation of resident's property would be reported immediately to the facility Administration, and appropriate state agencies would be notified by the facility's Administration within two hours.Review of R74's admission Record revealed the facility initially admitted the resident on 09/21/2024 with diagnoses which included atrial fibrillation, osteoarthritis, and congestive heart failure. He was admitted to the hospital on [DATE] for altered mental status and shortness of air. Per the record, the facility readmitted R74 on 10/31/2024.Review of R74's admission Minimum Data Set [MDS], with an Assessment Reference Date of 09/23/2024, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 14 out of 15, indicating intact cognition.Review of the Belongings Section, of R74's electronic health record, dated 09/23/2024, revealed no mention of money.Review of the e-mail from Registered Nurse (RN) 1 to the Director of Nursing and the Administrator on 11/09/2024 at 7:05 PM revealed a nurse notified her that R74 reported he was missing money from his wallet. In an interview with R74 on 08/13/2025 at 12:56 PM, he stated he did not remember the details, but he did have money missing from his wallet while he was admitted to the facility. He stated he reported it to the nurse and had not heard anything about the issue.The State Survey Agency (SSA) Surveyor attempted to reach RN1 for a telephone interview on 08/13/2025 and left a voice message for a return call. However, RN1 did not return the call.In an interview with the Director of Nursing (DON) on 08/13/2025 at 1:35 PM, she stated when the facility admitted a resident, the nurse could either enter the resident's belongings in the computer or put the information on a paper list. She stated if the nurse documented the belongings on paper, it was scanned into the resident's chart. The DON further stated when there was misappropriation of property, it should be reported as quickly as possible. However, she stated she did not know the timeframe for the report. She stated she was not part of the on-call process. She stated the Administrator was responsible for reporting any allegation of abuse.In an interview with the Administrator on 08/13/2025 at 2:04 PM, she stated the process for reporting misappropriation of property on the weekends was to report to her as soon as possible. She stated she was not sure what the regulations stated about the time for reporting misappropriation of property, but she thought it was 24 to 48 hours. She stated she reported the incident as soon as she was made aware. She stated she remembered the case and could not validate that anyone took R74's money. She stated she also had all the residents in the area questioned, and no other resident reported missing money.

4. A review of Resident #125's Coding Worksheet, indicated the facility admitted Resident #125 on 11/21/2023, with diagnoses that included orthopedic aftercare, personal history of other venous (related to a vein) thrombosis (formation of a blood clot) and embolism (obstruction of an artery), and long-term use of anticoagulants A review of Resident #125's physician orders revealed an order dated 11/22/2023, for enoxaparin (an anticoagulant medication that helped to prevent the formation of blood clots) 40 milligrams subcutaneous (applied under the skin) daily for deep vein thrombosis (DVT) prophylaxis (an action taken to prevent disease). A review of Resident #125's Interdisciplinary Plan of Care, dated 11/22/2023, did not include the resident's use of anticoagulant medication. During an interview on 11/30/2023 at 10:16 AM, the Licensed Practical Nurse (LPN) Minimum Data Set (MDS) Coordinator and the Registered Nurse (RN) MDS Coordinator stated the baseline care plan was initiated by the admitting nurse and if the nurse had knowledge the resident used a CPAP or BiPAP machine, it should be listed on the baseline care plan. During an interview on 11/30/2023 at 10:35 AM, the Director of Nursing (DON) stated the baseline care plan was initiated by the admitting nurse. The DON stated the use of a CPAP or BiPAP machine and anticoagulant medication should be included on a resident's baseline care plan. During an interview on 11/30/2023 at 10:40 AM, the Administrator stated care plans should be person-centered, accurate, and completed timely. The Administrator stated the use of high-risk medication and specialized equipment, such as CPAP or BiPAP machine, should be included on a resident's care plan. Based on observations, record reviews, interviews, and facility policy review, the facility failed to ensure baseline care plans included monitoring of high-risk medications and the use of non-invasive mechanical ventilators for four (4) of twelve (12) sampled residents (Residents #14, #82, #83, and #125). Findings included: A review of the facility policy titled, Baseline Care Plan, with an effective and initial date of 11/29/2023, revealed, The purpose of the facility Baseline Care Plan Policy is to outline a process for development of an initial person-centered care plan within the first 48 hours of admission, that will provide instructions for care of the resident. Completion and implementation of the baseline care plan within 48 hours of a resident's admission is intended to promote continuity of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events that are most likely to occur right after admission; and to ensure the resident and representative, if applicable, are informed of the initial plan for delivery of care and services by receiving a written summary of the baseline care plan. The policy specified, The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must - (i) Be developed within 28 hours of a resident's admission. (ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to - (A) Initial goals based on admission orders. (B) Physician orders. (C) Dietary orders (D) Therapy services. 1. A review of Resident #14's Coding Worksheet, indicated the facility admitted Resident #14 on 11/14/2023, with diagnoses that included obstructive sleep apnea and dependence on supplemental oxygen. A review of Resident #14's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/21/2023, revealed Resident #14 used oxygen therapy. A review of Resident #14's physician orders revealed an order dated 11/16/2023, for continuous positive airway pressure (CPAP) every night with home settings. A review of Resident #14's Interdisciplinary Plan of Care, with an admit date of 11/14/2023, did not include the resident's respiratory diagnosis of obstructive sleep apnea or the use of a non-invasive mechanical ventilator. On 11/27/2023 at 11:27 AM, the surveyor observed a CPAP machine (a machine that used mild air pressure to keep breathing airways open during sleep) on a stand next to Resident #14's bed. 2. A review of Resident #82's Facesheet, indicated the facility admitted Resident #82 on 11/14/2023. A review of Resident #82's physician orders revealed an order dated 11/14/2023, for continuous positive airway pressure (CPAP). A review of Resident #82's Interdisciplinary Plan of Care, with an admit date of 11/14/2023, did not include the resident's use of a non-invasive mechanical ventilator. On 11/27/2023 at 2:56 PM, the surveyor observed a CPAP machine (a machine that used mild air pressure to keep breathing airways open during sleep) on the nightstand next to Resident #82's bed. 3. A review of Resident #83's Coding Worksheet, indicated the facility admitted Resident #83 on 11/18/2023, with diagnoses that included obstructive sleep apnea and dependence on other enabling machines and devices. A review of Resident #83's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/25/2023, revealed Resident #83 used a non-invasive mechanical ventilator. A review of Resident #83's physician orders revealed an order dated 11/18/2023, for bi-level positive airway pressure (BiPAP) every night at bedtime. A review of Resident #83's Interdisciplinary Plan of Care, with an admit date of 11/18/2023, did not include the resident's use of a non-invasive mechanical ventilator. On 11/27/2023 at 11:37 AM, the surveyor observed a BiPAP machine (a machine which normalized breathing by delivery of pressurized air) on a stand next to Resident #83's bed.

Based on interviews, record review, and policy review, it was determined the facility failed to ensure there was evidence to indicate staff followed the physician's orders to obtain a finger stick blood sugar (FSBS) for one (1) of one (1) sampled resident reviewed for insulin use (Resident #6). Findings included: A review of the facility's policy titled, Diabetic Patient, reviewed on 06/28/2023, revealed, 1. Follow medical provider orders. A review of Resident #6's Coding Worksheet, revealed the facility admitted Resident #6 on 11/01/2023 with diagnoses to include type 2 diabetes mellitus. A review of Resident #6's physician orders revealed an order dated 11/01/2023, for glucose testing before meals and at bedtime. A review of Resident #6's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/08/2023, revealed Resident #6 had a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated the resident was cognitively intact. A review of Resident #6's care plan initiated on 11/13/2023 revealed the resident had diabetes. Interventions directed staff to monitor the resident's finger stick blood sugar (FSBS) as ordered by the medical provider and document. A review of Resident #6's Flowsheet Print Request, for the time period 11/01/23 to 11/29/2023, revealed no evidence staff checked Resident #6's blood sugar as ordered by the physician. A review of the Resident #6's Flowsheet Print Request, for the time period 11/01/2023 to 11/29/2023, revealed the resident's blood sugar was not checked on 11/01/2023 before breakfast and lunch; on 11/07/2023 at bedtime; on 11/08/2023 before breakfast, lunch, dinner, and bedtime; on 11/09/2023 before breakfast, lunch, and at bedtime; on 11/10/2023 before breakfast, lunch, and at bedtime; on 11/11/2023 at bedtime; on 11/12/2023 before breakfast; on 11/13/2023 before breakfast; on 11/14/2023 before lunch, dinner, and at bedtime; on 11/15/2023 before lunch, dinner, and at bedtime; on 11/16/2023 before breakfast and at bedtime; on 11/17/2023 before breakfast, lunch, and dinner; on 11/18/2023 before breakfast and lunch; on 11/19/2023 before breakfast and at bedtime; on 11/20/2023 before dinner and at bedtime; on 11/21/2023 before breakfast, lunch, and at bedtime; on 11/22/2023 before breakfast, lunch, and at bedtime; on 11/24/2023 before lunch, dinner, and at bedtime; on 11/25/2023 before breakfast, lunch, and dinner; on 11/26/2023 before dinner; on 11/27/2023 at bedtime; and on 11/28/2023 before breakfast and at bedtime. In an interview on 11/27/2023 at 1:32 PM, Resident #6 stated their FSBS was not checked before meals at the facility. During an interview on 11/29/2023 at 1:04 PM, Licensed Practical Nurse (LPN) #2 stated Resident #6 should have their FSBS (BS NOT FSBS) checked four times a day. LPN #2 reviewed Resident #6's Flowsheet Print Request and stated staff had not checked the resident's FSBS at bedtime as ordered by the physician. LPN #2 also reported the resident's FSBS was not checked as ordered on 11/28/2023 before breakfast or at bedtime. In an interview on 11/30/2023 at 9:41 AM, the Director of Nursing (DON) stated staff should follow the physician's orders for obtaining a resident's FSBS. The DON stated Resident #6 should have their FSBS checked before meals and at bedtime. The DON stated it was the nurse's responsibility to ensure the FSBSs were obtained and recorded in the resident's electronic medical record (EMR). The DON reviewed Resident #6's Flowsheet Print Request and acknowledged the staff did not check the resident's FSBS as ordered by the physician. During an interview on 11/30/2023 at 12:11 PM, the Administrator stated she would expect the staff to follow physician orders and the facility policy for obtaining a resident's FSBS. Per the Administrator, it was the nurse's responsibility to ensure FSBS results were obtained and recorded in the resident's EMR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of facility Policies, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary environment and to help prevent the development and transmission of communicable diseases and infections. Observation on 02/12/19, revealed Registered Nurse (RN) #1 performed a blood sugar fingerstick on Resident #115, and then placed the glucometer into the docking station without disinfecting the glucometer after use. ( A glucometer is a device used to measure the glucose in the blood). The findings include: Review of the facility's Policy, titled Care of Equipment revised 11/28/16, revealed equipment will be maintained to promote optimal use and appropriate infection control practices. Further review revealed all durable medical equipment is to be cleaned between each patient use. Review of the facility's Policy, titled Laboratory Policy and Procedure, undated, revealed the machine (glucometer, ACCU-CHEK Inform II System) is to be cleaned between use and whenever soiled with ten percent (10%) bleach towelette, or less than one percent (<1%) ammonium chloride (SANI-CLOTH) towelette. Review of the Manufacturer's Directions for the [NAME] ACCU-CHEK Inform II System, revised 02/01/13 revealed the meter must be cleaned with a damp (not wet) SANI-WIPE after each patient use. Observation on 02/12/19 at 11:19 AM, revealed RN #1 performed a finger stick on Resident #115. After performing the finger stick, RN#1 placed the glucometer into the docking station without disinfecting the glucometer. Interview with RN #1 during the observation, revealed the glucometers were to be cleaned once a day with a SANI-CLOTH. Interview with RN #2 on 02/13/19 at 10:15 AM, revealed glucometers were to be cleaned after each resident use in order to prevent cross contamination of bodily fluids from resident to resident. Interview with Licensed Practical Nurse (LPN#1), on 02/13/19 at 12:45 PM, revealed glucometers were to be disinfected after each use for infection control purposes. Interview with the Director of Nursing (DON), Infection Control Nurse, and Chief Nursing Officer, on 02/13/19 at 2:00 PM, revealed it was their expectation for staff to follow policies and procedures related to the glucometer and blood glucose testing. Per interview, the glucometers should be cleaned after each use to prevent the spread of infection and for resident safety.

2. Review of the facility's Policy, titled Care and Monitoring of Equipment in Patient Dining/Kitchenette Area of Inpatient Rehabilitation Units, reviewed 01/16/17, revealed food and nutrition products will be stored under proper conditions of sanitation, temperature, and security to maintain product stability. Care and upkeep of equipment on nursing units is the responsibility of Dietary, Housekeeping and Nursing Staff. Continued review of the Policy, revealed refrigerators and cabinets will be cleaned and wiped out monthly, or more frequently as needed, with a hospital approved disinfectant by Dietary staff. Further review revealed, all personnel are responsible for cleaning up spills. Observation on 02/12/19 at 3:10 PM, of the nourishment refrigerator on the skilled unit, revealed there was a dried yellow, sticky substance on a compartment door located on the interior side of the refrigerator door and a large amount of dried reddish, sticky, substance on the floor of the refrigerator. Food crumbs were also scattered on the floor of the refrigerator. Interview on 02/13/19 at 10:06 AM, with Rehab Nursing Technician (RNT) #1 and RNT #2, on the skilled unit, revealed Dietary Staff was in charge of the nourishment refrigerator being stocked, and nursing staff on the unit would clean up any spills. Interview on 02/13/19 at 10:10 AM, with the Nutrition Services Aide (NSA) #1, revealed she was primarily responsible for stocking the nourishment refrigerator on the skilled unit, and occasionally cleaned up spills that were really bad. NSA #1 further stated she was not sure who was responsible for cleaning the nourishment refrigerator. Interview on 02/13/19 at 10:30 AM, with the Director of Nursing (DON), revealed Dietary Staff stocked the nourishment refrigerator and cleaned the inside and Housekeeping cleaned the outside. She stated she had reminded nursing staff to clean up spills in the nourishment refrigerator if they should see them. Interview on 02/13/19 at 2:41 AM, with the Account/ Dietary Manager, revealed she was unaware there was a policy regarding the maintenance of the refrigerators and that dietary was ultimately responsible for cleaning inside the nourishment refrigerators. Interview on 02/13/19 at 3:54 PM, with the Chief Nursing Officer/Administrator, revealed spills in the nourishment refrigerator could foster harmful bacteria and needed to be cleaned up right away. Based on observation, interview, and review of facility Policy, it was determined the facility failed to prepare and serve food under sanitary conditions. Observation on 02/12/19 of the lunch meal service, revealed Dietary Staff failed to use proper hand hygiene as necessary during tray line. Also, during the same lunch meal service, Dietary Staff was observed to wash hands in less than five (5) seconds. In addition, observation during the same lunch meal service, revealed staff failed to obtain food temperatures using proper technique to prevent cross contamination of foods. Furthermore, observation on 02/12/19, of the nourishment refrigerator on the skilled unit, revealed there was dried residue and food crumbs. The findings include: 1. Review of the facility Policy titled Hand Hygiene dated 03/04/18, revealed the purpose of hand hygiene is to decrease the risk of transmission of infection by appropriate hand hygiene. Hand washing is the most important means of preventing the spread of infection. All employees are to use proper hand hygiene and hand washing techniques within the facility. Wash hands after removing gloves, before and after handling food. Continued review of the Policy, revealed proper hand washing technique includes: turning water on, and moistening hands with soap and water into a heavy lather; washing hands under running water for a minimum of twenty (20) seconds with a rotary motion and friction; rinsing hands under running water; turn off the faucet with a paper towel; and dry hands with a clean paper towel and discard. Observation on 02/12/19 at 10:45 AM, revealed during lunch tray line, Dietary Aide#1 ran into the tray line table. A bin fell off and spilled packaged dressing and three (3) margarine packs onto the floor. Dietary Aide# 1 picked up items from the floor; however, did not wash hands and continued to prep for the lunch tray line with the same soiled gloves. In addition, Dietary Aide # 1 was observed to touch her clothing while talking with another Dietary staff member near the lunch tray line, and then continued working on the lunch tray line. Dietary Aide# 1 subsequently washed her hands and changed her gloves; however the hand washing took less than five (5) seconds. Observation on 02/12/19 at 11:00 AM, revealed [NAME] #1 was taking food temperatures during tray line at the steam table while talking on her phone and writing with a pen. The cook then put the pen and phone in her pocket and without washing hands, proceeded to continue to take the food temperatures. Further observation revealed [NAME] #1 used one (1) sanitary wipe to sanitize the thermometer between all food items by folding the wipe over several times. Interview on 02/13/19 at 2:28 PM, with Diet Aide# 1 and Cook#1, revealed hands should be washed for at least sixty (60) seconds. Further interview revealed hands should be washed if items were touched such as clothing, phone or pen to prevent cross contamination. Additional interview revealed hands should be washed after picking up items in the floor when working in the kitchen. Further interview revealed the thermometer stem should be cleaned with a new separate wipe in between each food or the wipe could be folded over in between each food when taking food temperatures. Interview on 02/13/19 at 2:14 PM, with the Dietary Supervisor, revealed hands should be washed for fifteen (15) seconds in order to prevent cross contamination. Per interview, hands should be washed after touching clothing, or picking up items from the floor while working in the kitchen. Continued interview revealed the [NAME] and Dietary staff should have washed their hands and changed gloves after touching their phones, pen and clothes to prevent cross contamination. Further interview revealed the thermometer stem should be cleaned with a new separate wipe in between each food item when taking food temperatures to prevent cross contamination. Interview on 02/13/19 at 2:34 PM, with the Account/Dietary Manager, revealed Dietary staff was to wash hands the length of time it would take to sing Happy Birthday twice. Further interview revealed Dietary Staff should wash hands after touching their clothing, a pen or phone while working in the kitchen. Continued interview revealed Hands should be washed after picking up items from the floor to prevent cross contamination. Additional interview, revealed staff should use one (1) new wipe to clean the thermometer in between each food item while taking food temperatures to prevent cross contamination. Interview on 02/13/19 at 3:27 PM, with the Director of Nursing (DON), revealed Dietary Staff should wash hands after touching items such as their phone or clothes or pen. Further interview revealed staff should wash hands after picking items up off the floor to prevent cross contamination. Per interview, staff should wash hands for two (2) minutes. Interview on 02/13/19 at 3:36 PM, with the Chief Nursing Officer/Administrator, revealed staff were provided training concerning proper hand washing and glove usage. Per interview, staff should wash hands between serving, receiving, and preparing any type of food, and during every step of the process. Further interview revealed Dietary Staff should wash hands after touching personal items or picking items up off the floor. Per interview, germs were on all surfaces and could transfer and contaminate food items. Continued interview revealed staff should wash hands thoroughly for thirty (30) seconds. Additional interview revealed food the correct process for obtaining food temperatures was to clean the thermometer with a new wipe between obtaining temperatures of different food items to prevent cross contamination.