Based on observation, interview, facility policy review, and record review, the facility failed to ensure a resident was free from the use of a physical restraint when facility staff loosely wrapped a resident's legs in a sheet to prevent the resident from removing his brief for one (1) of three (3) sampled residents. Resident #1 Findings include: A review of the facility policy, Use of Restraints, revised December 2007, revealed, .Policy Interpretation and Implementation 1. 'Physical Restraints' are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily .4. Practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted, including .b. Tucking sheets so tightly that a bed-bound resident cannot move . A record review of the admission Record revealed the facility admitted Resident #1 on 12/17/24 with diagnoses including Parkinson's Disease. A record review of the Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/18/25 revealed a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident's cognition was severely impaired. A record review of the medical record revealed there was no documentation indicating Resident #1 had assessments, interventions, or Physician Orders for the use of a physical restraint. A record review of the Progress Note dated 5/8/25 at 6:18 (AM) revealed: AROUND 5:40 AM ON THIS MORNING 05/08/2025 THIS NURSE ENTERED THIS RESIDENT'S ROOM TO OBTAIN VITALS TO ADMINISTER MEDICATIONS. ONCE IN THE ROOM, THIS NURSE NOTICED THIS RESIDENT TUGGING AT HIS SHEET ON HIS LOWER EXTREMITIES .THIS NURSE FOUND THAT THE RESIDENT'S LEG HAD BEEN BOUND TOGETHER WITH TAPE .THE RESIDENT RESPONDED SAYING THANK YOU . The entry was signed by Licensed Practical Nurse (LPN) #1. A review of the facility's investigation revealed that on 5/8/25, LPN #1 reported to the Director of Nursing (DON) that Resident #1 was found with a sheet wrapped around his legs and secured with tape. Certified Nurse Aides (CNAs) stated the intervention was used because the resident was frequently pulling off his brief and smearing feces. The tape was approximately six (6) inches long and placed mid-calf, over the sheet. The resident's arms and feet were not restricted. A red area was noted by the nurse, which resolved within an hour. On 5/19/25 at 6:15 PM, during an observation, Resident #1 was non-verbal, and was laying in his bed with sheets over his lower extremities. His bed was in the low position with a floor mat next to bed. On 5/20/25 at 10:00 AM, during an interview with LPN #1, she confirmed she found Resident #1 with his legs wrapped in a flat sheet and a piece of tape. She immediately removed the tape and sheet and notified the DON. She confirmed she did not leave the items in place for a witness to observe. On 5/20/25 at 10:20 AM, during an interview with CNA #1, she confirmed that she and CNA #2 attempted to prevent the resident from removing his brief by placing him in a burrito wrap using a sheet and secured it with tape. She confirmed he could move his arms and legs, and the tape was not in contact with his skin. On 5/20/25 at 12:24 PM, during an interview with CNA #2, she explained they wrapped the sheet around the resident's lower body and applied a six (6) inch piece of tape across the sheet to keep him from accessing his brief. She confirmed the intervention was not ordered or approved. On 5/20/25 at 12:30 PM, during an interview with the Director of Nursing, she confirmed the sheet and tape were applied to control the resident's behavior without a physician's order or care plan intervention. She stated the resident retained full movement of upper extremities and feet. There was no injury observed, and there was a reddened area that resolved within one (1) hour. She confirmed the intervention was deemed a violation of policy but not abuse. The CNAs involved received suspensions and re-education. On 5/20/25 at 12:45 PM, during an interview with the Administrator, she confirmed the incident was thoroughly investigated and concluded the resident retained the ability to remove the sheet and tape. She emphasized the action was a policy violation, not abuse, and the CNAs were suspended and retrained. She stated the State Agency would have been notified if criteria for abuse had been met. On 5/20/25 at 1:15 PM, during an interview with Registered Nurse (RN) #1 and the DON present, she confirmed that no bruises, scratches, or skin tears were observed. The healing scabbed area on the right calf had been present before the incident. She confirmed the tape did not touch the skin.

Based on observation,interviews, facility policy review and record review, the facility failed to ensure residents had access to a call light while in bed for two (2) of 18 residents sampled (Residents #1 and #12). Findings include: A review of the facility's policy, Call Light, Use Of, revised on 05/22/2012, revealed: .position the call light conveniently for the resident to use . Be sure all call lights are placed on the bed at all times, never on the floor or bedside stand . A review of the facility's Resident Rights revealed The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside .the facility. Resident #1 On 02/24/2025 at 03:49 PM, an observation of Resident #1 revealed the resident calling for help from his room. The resident's call light was observed to be draped over the call light box located on the wall. The resident was observed to have an amputated leg. The resident stated he was unable to get out of bed to reach the call light from the call light box on the wall. The resident stated the call light was normally on his bed. On 02/24/2025 at 03:50 PM, an interview with Certified Nursing Assistant (CNA) #1 acknowledged the call light was draped over the call light box and was out of the resident's reach. CNA#1 noted that residents' call lights should always be accessible for their safety and stated everyone is responsible for making sure residents have their call lights within reach. A record review of the facility's admission Record revealed the facility admitted Resident #1 on 07/16/2021, with diagnoses including Acquired Absence of Left Leg Below the Knee. A record review of the annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/07/2025 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Resident #12 On 02/24/2025 at 03:45 PM, observed Resident #12 calling out for help while in her room. The resident stated she was not able to use her call light because she could not see it. The resident explained that she cannot see very well. The resident's call light was observed on the floor under the head of her bed. The resident stated the call light is usually located on her bed within reach. On 02/24/2025 at 03:47 PM, an interview with Licensed Practical Nurse (LPN) #1, Charge Nurse, acknowledged that Resident #12's call light was out of reach and on the floor. LPN #1 noted that not only CNAs but floor nurses as well should assist in making checks to ensure residents' call lights are within reach. LPN #1 stated her expectation would be that residents' call lights should be within reach at all times. A record review of the admission Record revealed that the facility admitted Resident #12 on 10/31/2024, with diagnoses including Unspecified Visual Loss. A record review of the quarterly MDS with an ARD of 12/20/2024 revealed Resident #12 had a BIMS score of 06, indicating severe cognitive decline. On 02/26/2025 at 01:50 PM, an interview with the Director of Nursing (DON) acknowledged that the call lights for Residents #1 and #12 were out of reach. The DON stated that call lights should always be within reach for every resident. She further stated that the entire nursing staff is responsible for ensuring residents have access to their call lights. The DON emphasized the importance of residents being able to access their call lights to call for assistance and stated the facility's expectation is that all call lights should be clipped to the bed and within reach. The DON noted that she plans to conduct rounds to ensure residents' call lights remain within reach. On 02/27/2025 at 02:13 PM, an interview with the Administrator acknowledged that the call lights for Residents #1 and #12 were out of reach. The Administrator emphasized the importance of residents having call lights within reach so they can call for help. The Administrator stated that he expects nursing staff to assist residents by ensuring their call lights remain accessible at all times.

Based on observations, interviews, record review and facility policy review, the facility failed to ensure Resident #74 had a safe, clean, and homelike environment for two (2) of four (4) days of facility observations. Findings include: A record review of the Resident Rights, in Section H revealed .1. The facility must provide a safe, clean, comfortable, and homelike environment .2. Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior . record review of the Seven-Step Deep Cleaning, revised 2/04/14 revealed that cleaning steps include: Disinfecting all surfaces . disinfecting all furniture . inspection of room . On 02/25/2025 at 02:41 PM, an observation of Resident #74 in bed revealed the bed frame, walls, curtains, and bed rails were stained. Resident #74's room had an odor. The resident stated that his room is cleaned daily. On 02/25/2025 at 02:45 PM, an interview with Certified Nurse Aide (CNA) #3 revealed that Environmental Services is responsible for keeping rooms clean, including wiping walls and bed frames. On 02/25/2025 at 02:50 PM, an interview with Environmental Services (EVS) Worker #1 revealed that staff clean rooms daily. Routine cleaning includes dusting furniture, cleaning the bathroom, taking out the trash, and wiping off bed frames when dirt and debris are visible. On 02/26/2025 at 08:42 AM, a phone interview with the EVS Manager revealed that resident rooms receive detailed cleaning three (3) times per week. Detailed cleaning includes walls cleaned, bed frames wiped off, mattresses wiped (if wipeable), furniture dusted, trash removed, bathrooms cleaned, and bed rails sanitized. The EVS Manager stated that deep or detailed cleaning can occur when residents are out of the room. On 02/26/2025 at 08:48 AM, an observation revealed Resident #74 was in bed. The bed frame, walls, curtains, and bed rails remained stained. On 02/26/2025 at 09:10 AM, an observation of Resident #74's room was made by the State Agency and the EVS Manager. This observation revealed a stained bed frame, walls, curtains, and bed rails. The EVS Manager acknowledged the brown stains on the bed frame, curtains, walls, and bed rails. The EVS Manager stated that she would contact laundering services to remove the curtains and clean them. On 02/27/2025 at 08:14 AM, a phone interview with the EVS Manager revealed that her expectation of EVS staff is to clean rooms according to policy. She stated that nursing staff should inform EVS staff when a resident's room is not clean or needs a deeper cleaning. The EVS Manager acknowledged the stains on the walls, bed rails, bed frame, and curtains and stated that she believed the stains were dried food on the walls, bed frame, curtains, and bed rails. On 02/27/2025 at 01:33 PM, an interview with the Director of Nursing (DON) revealed that EVS staff are expected to clean resident rooms daily. The DON stated that if CNAs observe stains on residents' walls, bed frames, or bed rails, they should clean them between EVS daily cleanings.

Based on observation, interviews, record review and facility policy review, the facility failed to label and date food items in the refrigerator, freezer, and dry good rooms for one (1) of four (4) observations. Findings included: A review of the facility's Food Preparation policy, undated, revealed, .Discard foods that are not date marked ., TCS (Time/Temperature Control for Safety) foods that was opened or prepared seven (7) days prior . A review of the facility's Labeling policy, undated, revealed .Ensure all food items are labeled. Be especially cautious to label all food items that are not kept in their original containers . Ready -to-Eat TCS food . On 02/24/25 at 09:45 AM, during an observation and interview with the Dietary Manager (DM), there was (1) clear plastic bag of boiled eggs unlabeled without a used by or prepared date. In the freezer, there was an unlabeled box of assorted mini cheesecakes, (1) bag of hushpuppies opened, without product opened date. During tour of dry goods room, there was an opened, exposed, an unlabeled box of graham cracker crumbs, and two (2) sweet potatoes that shows deterioration. The DM confirmed the unlabeled items in the refrigerator, freezer, and dry goods room. On 2/27/25 at 2:56 PM, in an interview with the Administrator, confirmed he was had been informed of the findings in the kitchen.

Based on record review and facility policy review, the facility failed to have mandatory members of the Quality Assurance Performance Improvement (QAPI) Committee present for (4) four of 12 months reviewed. Findings include: A record review of the facility's QAPI sign in logs revealed the Infection Preventionist (IP) was not present for the meeting on 3/20/24, 5/15/24, 6/19/24, and 7/17/24. On 02/27/25 at 02:37 PM, an interview with Registered Nurse #1/Quality Assurance (QA) nurse revealed the IP was not present for four (4) QAPI meetings in 2024. The QA nurse revealed the purpose of having all required disciplines present is that all ideas can be heard and that the department that is affected by a topic can provide input or receive information. The QA nurse stated the nursing home has had a lot of turnover of staff and going forward she expects all required disciplines to be present. On 02/27/25 at 02:59 PM, during an interview with the Administrator, he acknowledged the IP nurse was not present for four (4) QAPI meetings in 2024. The Administrator revealed the purpose of having all required disciplines present is to provide correct communication between the disciplines regarding patient care issues. The Administrator stated that going forward he expects all required disciplines to be present at the QAPI meetings.

Based on observation, interviews, record review, and facility policy review, the facility failed to serve meals within the 14-hour timeframe without providing a substantial snack for one (1) of four (4) days of survey. Findings included: A review of the facility's policy titled Resident Nutrition Services, revised in July 2017, revealed, Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident .7. Nourishing snacks are available to the residents 24 hours a day. The resident may request snacks as desired, or snacks may be scheduled between meals to accommodate the resident's typical eating patterns . A record review of the facility's Meal Serving Schedule, updated on 04/04/2023, revealed that dinner for Station Two (2) starts at 4:00 PM to 4:20 PM, and breakfast is served at 7:15 AM to 7:35 AM, resulting in 15 hours and 15 minutes between dinner and breakfast. The schedule also revealed that dinner for Station One starts at 4:20 PM to 4:40 PM, and breakfast is served at 7:35 AM to 7:55 AM, resulting in 15 hours and 10 minutes between dinner and breakfast. A record review of the facility's Cart Delivery Log, dated 02/25/2025 to 02/26/2025, revealed that Station Two received the dinner meal cart on the floor at 4:06 PM on 02/25/2025 and received the breakfast meal cart on 02/26/2025 at 7:28 AM, resulting in a 15-hour and 22-minute lapse between dinner and breakfast. The log also revealed that Station One received their dinner cart at 4:30 PM on 02/25/2025 and their breakfast meal cart at 7:55 AM on 02/26/2025, resulting in a 15-hour and 20-minute lapse between dinner and breakfast. ON 02/25/25 at 4:00 PM, in an observation, the dinner meal trays on 200 Hall at 4:04 PM. The first tray was served at 4:09 PM. The second dinner cart arrived at 4:16 PM and the diabetic nigh snacks were served in brown bags with resident room numbers on the front. Residents in the Dining Hall received their meal tray at 4:22 PM to residents in Dining Hall. On 02/25/2025 at 4:49 PM, during an interview, Dietary Staff #1 stated that the previous Administrator and Director of Nursing (DON) decided approximately six (6) to seven (7) months ago to stop the snack cart due to residents wanting snack options, such as soup, cereal, and sandwich, instead of chips, crackers, and snack cakes. Now the kitchen supplies the nurses' station with snacks, sandwiches with meat and bread, and residents can request these items. Dietary Staff #1 explained that diabetic residents receive snacks automatically with their dinner trays. Dietary Staff #1 defined a suitable snack as juice, a sandwich, graham crackers, a beverage, or soup. On 02/26/2025 at 7:38 AM, during an interview, Licensed Practical Nurse (LPN) #2 confirmed that there is no documentation indicating who receives a snack. LPN #2 explained that each non-diabetic resident must request a snack, whereas diabetic residents receive snacks automatically with their dinner meal. On 02/27/2025 at 1:23 PM, during an interview, Dietary Staff #2, the newly appointed Dietary Manager, stated that she did not know who set the mealtimes and was unaware that there were more than fourteen (14) hours between the dinner meal and the breakfast meal. She stated that she believed snacks were offered to all residents between 7:00 PM and 9:00 PM but was unaware that residents were not receiving a substantial snack. On 02/27/2025 at 1:31 PM, during an interview, Dietary Staff #3 stated that she was unaware that the meal schedule exceeded fourteen (14) hours between dinner and breakfast. She stated that the three meals served daily met residents' nutritional needs but was unaware that residents were not offered snacks at night. On 02/27/2025 at 1:44 PM, during an interview, the Director of Nursing (DON) stated that she did not know who set the mealtimes, but they had been in place since she started working at the facility. The DON stated she was unaware that residents waited longer than fourteen (14) hours between meals and that snacks were not routinely offered. She confirmed awareness of the resident council's decision to remove the snack cart but was unsure why the decision was made. On 02/27/2025 at 2:05 PM, during an interview, the Administrator stated that he was unaware that residents waited longer than fourteen (14) hours between dinner and breakfast and that residents were not offered snacks at night. The Administrator stated that he expected residents to be offered a substantial snack between meals.

Based on interview, record reviews, and facility's policy review the facility failed to ensure the comprehensive care plan interventions were implemented when a resident was transferred with a mechanical lift without the assistance of two (2) staff members for one (1) of 23 sampled residents. Resident #6 Findings include: Review of the facility's policy, Care Plans, Comprehensive Person -Centered, revised December 2016, revealed, .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is . implemented for each resident . Record review of the Comprehensive Care plan, dated 7/6/23, revealed . Category: Seizures . Intervention .Total Assist X 2 for transfers with use of Hoyer Lift (mechanical lift) . On 8/24/23 at 09:00 AM, an interview with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) revealed CNA #1 and CNA #2 had been terminated from the facility for not following the facility policy which required two persons when transferring a resident with a mechanical lift. The DON stated that they re-interviewed both employees and found that CNA #1 had transferred Resident #6 to the shower stretcher without the appropriate number of staff and CNA #2 had transferred Resident #6 from the shower stretcher to her bed without the required number of staff. On 8/24/23 at 11:00 AM, in an interview with Certified Nurse Aide (CNA) #1, she confirmed she transferred Resident #6 to the shower stretcher with a mechanical lift and did not have another staff member to assist. She stated that she had been trained in her CNA class to always have two people when transferring a resident with a mechanical lift. On 8/24/23 at 11:15 AM, with CNA #2, she confirmed she transferred Resident #6 from the shower stretcher to the bed without another staff member assisting. She stated that had been trained to have two staff members when using the mechanical lift. On 08/24/23 at 11:52 AM, during an interview with Registered Nurse (RN)#4, she explained that the purpose of the care plan was for facility staff to understand and know what to do for residents to meet the residents' needs. She stated that all resident care plans are located on the residents' chart at the nurse's station and on the computer. RN #4 reported that she expected the staff to follow the resident's care plan. Record review of the Face Sheet revealed the facility admitted Resident # 6 on 9/05/07 and she had diagnoses including Paraplegia, Multiple Sclerosis, and Osteoporosis. Record review of the Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/23/23 revealed Resident #6 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated Resident # 6 was cognitively intact. Further review revealed Resident #6 was dependent upon facility staff for transferring and required two persons to assist with the transfers.

Based on interviews, record review, and facility policy review the facility failed to ensure a resident who was transferred using a mechanical lift was transferred with appropriate supervision for one (1) of three (3) sampled residents transferred with mechanical lifts. Resident #6 Findings include: Review of the facility's policy, Lifting Machine, Using a Portable, revised September 2017, revealed, .The purpose of this procedure is to help lift residents using a manual lifting device .General Guidelines Two (2) nursing assistants are required to perform this procedure . An interview on 8/24/23 at 09:00 AM, with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON), revealed Certified Nurse Aide (CNA) #1 and CNA #2 had been terminated from the facility for not following the facility policy which required two persons when transferring a resident with a mechanical lift. The DON stated that during an incident investigation, the CNAs were interviewed again and it was discovered that CNA #1 had transferred Resident #6 to the shower stretcher without using the required number of staff and CNA #2 had transferred Resident #6 from the shower stretcher to her bed without the appropriate number of staff. During an interview on 8/24/23 at 11:00 AM, with CNA #1, she confirmed she transferred Resident #6 to the shower stretcher with a mechanical lift and did get another staff member to assist her. CNA #1 said she showered the resident and took her to her room. During an interview on 8/24/23 at 11:15 AM, with CNA #2, she confirmed she transferred Resident #6 from the shower stretcher to the bed without another staff member assisting. She stated that Resident #6 was on the shower stretcher in her room and she cut the resident's hair and transferred her back to her bed. CNA #2 explained that she was aware that the facility required two (2) staff when using a mechanical lift. Record review of the Face Sheet revealed the facility admitted Resident # 6 on 9/05/07 and she had diagnoses including Paraplegia, Multiple Sclerosis, and Osteoporosis. Record review of the Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/23/23 revealed Resident #6 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated Resident # 6 was cognitively intact. Further review revealed Resident #6 was dependent upon facility staff for transferring and required two persons to assist with the transfers.

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure a resident rinsed her mouth after the administration of a Metered-Dose Inhaler to prevent possible mouth and throat irritation for one (1) of one (1) resident observed for administration of a Metered-Dose Inhaler. Resident #26 Findings include: A record review of the facility's policy Administering Medications through a Metered Dose Inhaler, revised 10/2010, . The purpose of this procedure is to provide guidelines for the safe administration of inhaled medications . Equipment and Supplies .5. Gargling solutions . On 08/22/23 at 03:50 PM, during an observation of medication administration with Registered Nurse (RN) #1, she administered two (2) puffs of the Flovent inhaler and exited the room without instructing the resident to rinse her mouth. On 08/23/23 at 01:30 PM, during an interview with RN #1, she confirmed that on 08/22/23 while administering the Flovent Inhaler to Resident #26, she did not offer the resident water to rinse and expectorate. RN #1 reviewed the guidelines for the use of the medication and confirmed the resident should have rinsed her mouth after the administration of the Flovent inhaler to prevent thrush and other complications. On 08/23/23 at 01:45 PM, during an interview with the Director of Nursing (DON), she explained she expected the nurses to follow the guidelines for medication administration and confirmed the reason for instructing residents to rinse after the administration of a steroid inhaler is to prevent possible complications. A record review of the Face Sheet revealed the facility admitted Resident #26 on 11/04/2016 with the diagnosis of Chronic Obstructive Pulmonary Disease. A record review of the Physician Orders List revealed Resident #26 had a Physician's Order dated 10/7/2019 for Flovent HFA (Fluticasone Propionate) 0.1 mg (milligram) inhaler. Give two puffs via inhalation four times daily. Allow one minute between inhalations. Rinse mouth with water after use . A record review of the Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/11/2023, revealed Resident #26 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated she had moderate cognitive impairment. A record review of the Patient Information document for Flovent HFA for oral inhalation use, revised 4/2020, revealed . Rinse your mouth with water without swallowing after each dose of Flovent HFA. This will help lessen the chance of getting a yeast infection (thrush) in your mouth and throat .