Every finding on record at Ascension Resurrection Life

Based on observation, interview, and record review, the facility failed to maintain residents and staff documentation of screening, education, offering, and current COVID-19 vaccination status. These failures are not in accordance with their policies and procedures and CDC (Centers for Disease Control and Prevention) guidelines. Multiple residents and facility staff were positive of Covid infection that were either not up to date with COVID-19 immunization or unvaccinated that can potentially affect all 51 residents in the facility.Findings include: Per Outbreak log provided by V4 (Quality Director/Infection Nurse/Registered Nurse) there are twenty-eight (28) residents on the first outbreak started on 12/31/2025, that tested positive with COVID infections. Out of twenty-eight (28) residents there are eighteen (18) residents (R1, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22 and R26) positive of COVID infections that were either not up to date with COVID-19 vaccination or unvaccinated. First Outbreak resulted to four (4) residents hospitalized due to COVID infection:R9 symptoms include decrease of oxygen saturation and altered mental status. Latest vaccination was on 05/02/2022.R16 symptoms include shortness of breath and poor appetite. R16 is unvaccinated.R22 symptoms include vomiting and tachycardia (elevated heart rate). Latest vaccination on 10/30/2023.R3 latest vaccination was on 11/19/2024.All residents that were hospitalized were either not up to date with COVID-19 vaccination or unvaccinated. There were ten (10) facility staff that includes:V9 (MDS Coordinator / RN) tested positive on 12/29/2025 prior to declaration of outbreak.V6 tested positive on 12/29/2025 prior to declaration of outbreak.V10 (Certified Nursing Assistant) tested positive on 01/04/2026.V11 (Registered Nurse) tested positive on 01/04/2026.V12 (Occupational Therapist) 01/05/2026.V13 (Registered Nurse) tested positive on 01/08/2026.V14 (Certified Nursing Assistant) tested positive on 01/08/2026, V15 (Registered Nurse) tested positive on 01/18/2026.V16 (Registered Nurse) tested positive on 01/12/2026.V17 (Registered Nurse) tested positive on 01/12/2026. All ten (10) of the facility staff were positive with COVID infection were either not up to date with COVID-19 vaccination or unvaccinated. Prior to facility's declaration of first COVID infection outbreak on 12/31/2025, two (2) of the facility staff V9 (MDS Coordinator) and V6 (Registered Nurse) were tested positive on 12/29/2025 showing symptoms that include cough, congestion, low grade fever and headache. Facility then declared second outbreak that started on 02/13/2026 with ten (10) residents tested positive with COVID infection. Out of 10 residents, 4 residents (R26, R28, R29 and R31) were either not up to date with COVID-19 vaccination or unvaccinated.Second Outbreak hospitalized Resident due to COVID infection:R26 symptoms include fever and fatigue. R26 was not up to date with COVID-19 vaccine, latest vaccination was on 10/11/2022.R28 tested positive for COVID on 2/16/26. R28's symptoms included fatigue. R28 was not up to date with COVID-19 vaccine, latest vaccination was on 4/2/2021.R31 tested positive for COVID on 2/16/26. R31's symptom included sore throat. R31 was not up to date with COVID-19 vaccine, latest vaccination was 12/2/2021. R1 declined vaccine 2/11/26.On 05/20/2016 at 01:10 PM, V4 (Infection Nurse) stated that facility reported an outbreak on 12/31/2025, then declared outbreak free on 02/02/2026, after 14 days without new case of COVID infection. On 02/13/2026, a second outbreak was reported due to residents becoming positive with COVID infection. V4 stated per CDC (Centers for Disease Control and Prevention) guidelines year 2025 it is recommended for residents to have updated COVID-19 vaccine after six (6) months of receiving the vaccine and for those ages 65-years-old and above.V4 stated that R29 did not receive his COVID-19 vaccination due to taking antibiotic at that time. R29's immunization record documents that COVID-19 vaccine was pending administration since 01/14/2026. Most recent COVID-19 vaccination of R29 was on 10/04/2024 making R29 not up to date with COVID-19 immunization. R29 was tested positive for COVID infection on 02/16/2026 during declaration of second outbreak with symptoms include runny nose, nasal congestion and headache.V4 stated that it was facility staff (V9 and V6) that was first identified as positive with COVID infection prior to declaring first outbreak. V4 stated that currently she does not have a list of facility staff vaccination status because corporate handles submission of COVID-19 vaccination status of staff. V4 stated that there are more facility staff that were positive with COVID infection besides V9 and V6 including therapist, nurses and nursing assistants. V4 stated that she can coordinate with HR (human resources) to get the list. After request of consent forms for residents identified positive with COVID infection. V4 stated that facility currently she is working to include consent forms with resident's medical records. V4 stated that consent forms are in a separate binder that is separate from resident's electronic health record. V4 stated that facility needs to improve on being able to attach forms to resident's medical record. V4 said, I need to upload consents of residents that was infected with COVID-19. Vaccination consent forms were not provided at this time. On 05/21/2026 at 10:46 AM, V4 stated that R3 was not included in the list of Outbreak log because at that time R3 was in the hospital. Per R3's immunization records, COVID-19 vaccination is not up to date. R3's last COVID-19 vaccination was on 11/19/2024. CDC on Staying Up to Date with COVID-19 Vaccines dated 11/19/2025: CDC recommends a 2025-2026 COVID-19 vaccine for people ages 6 months and older based on individual-based decision-making. The COVID-19 vaccine helps protect you from severe illness, hospitalization, and death. It is especially important to get your 2025-2026 COVID-19 vaccine if you are ages 65 and older, are at high risk for severe COVID-19, or have never received a COVID-19 vaccine. Per facility's Covid-19 policy dated 06/2025: Policy is meant to establish guidelines to enhance efforts to identify cases of Covid-19 quickly and to implement interventions and reduce exposure risks for the residents and associates/staff. Facility's routine infection prevention and control practices for Covid-19 include vaccinations. Per policy, Health Care Providers and Residents will be provided education on risks and benefits of the Covid-19 using CDC vaccination information sheet. Residents will be offered the Covid-19 vaccination to remain up to date with the most current CDC vaccination schedule. Per facility's Infection Prevention and Control Program dated 06/2025:Immunization is a form of primary prevention. Residents and Associates will be provided education on vaccinations. Residents will be offered Covid-19 vaccination per recommended schedule by the CDC. Refusals of any immunization will be documented in the medical records indicating the date of refusal.

Based on interview and record review, the facility failed to provide interventions to prevent a resident from developing wounds due to immobilizer/brace skin friction. Facility also failed to consistently document physician orders were being followed/given on the treatment administration record (TAR) and on the medication administration record (MAR) for 1 (R1) out of 3 residents reviewed for quality of care. Findings include: R1 was a resident in the facility re-admitted on [DATE] and was discharged on 03/07/2026. R1 is cognitively intact with BIMS (Brief Interview of Mental Status) score of 15. R1 upon admission uses right leg immobilizer/brace due to right lower leg fracture. R1's Braden Scale assessment was not up to date. Latest Braden Scale assessment was done on 11/11/2025, before admission of R1 on 12/24/2025 when R1 does not have right leg immobilizer/brace. Braden Scale assessment is a tool that would help identify risk for pressure ulcers. R1 has the following physician orders:R1 must wear fracture brace at all times and record it three (3) times a day on treatment administration record (TAR). Multiple days were not documented as being performed.Per Weekly Skin Assessment Skin Integrity Review dated 12/24/2025 documents unable to check RLE (Right Lower Extremity) due to R1's refusal due to pain.R1 was then scheduled for a weekly skin assessment on treatment administration record (TAR) which was not documented as done on 12/25/2025 and 01/08/2026.Per Skin Evaluation Form dated 01/12/2026, R1 sustained traumatic wound on right outer ankle due to the brace. Measurement in centimeter 2.5 length, 2.0 width and 0.2 depth.On 01/23/2026 V18 (Medical Doctor Wound) in his initial Wound Evaluation and Management Summary of R1's right ankle wound documents that wound has enlarged quite a bit. Leg brace was discontinued. Suspicion of infection on the right ankle wound.On 01/26/2026, right ankle wound culture specimen was collected. On 01/29/2026, result was positive for infection (Staphylococcus Aureus MRSA and Pseudomonas Aeruginosa). To address R1's right ankle's infection, antibiotic Gentamicin ointment and Zyvox oral medication were ordered with wound treatment of Santyl. Multiple dates on medication administration record for February 2026 were not documented or signed as being administered. On 05/20/2026 at 10:09 AM interviewed V5 (Manager/Wound Nurse/Registered Nurse) and V2 (Director of Nursing). V5 stated that upon admission on [DATE], R1 was wearing a brace for right leg fracture during that time she does not have any wound on that area. Wound (right ankle) was identified on 01/12/2026 per resident record. V2 after reviewing R1's treatment administration record stated that weekly skin assessment supposed to be documented on 01/08/2026 prior to first identification of wound. V5 stated that R1 was positive for infection on culture that was done on 01/26/2026. An antibiotic was ordered by the doctor that includes Gentamicin ointment. V2 stated that there was an order also for Santyl ointment for wound treatment to help wound healing. After reviewing medication administration record (MAR) of R1. V2 stated that it is supposed to sign in the MAR that it was being administered. V2 stated that there should be intervention to prevent right lower leg for developing a wound due to leg immobilizer/brace used. It cannot be avoided that immobilizers/braces will produce friction in the skin. V2 stated that she will check for any interventions. At 2:20 PM, V2 stated that she cannot find intervention on preventing wounds on the right lower leg specific to using leg brace. On 05/21/2026 at 01:15 PM, V18 (Medical Doctor Wound) stated that R1's immobilizer or brace does not fit well that the plastic cut her ankle resulting to like an abrasion. V18 stated that form fitting of the brace does not fit well needing adjustment. V18 stated that hydrocolloid dressing can be used to prevent wounds due to friction of the brace. Hydrocolloid dressing is thick and helps with friction. V18 stated that R1 has thin that can easily expose her tendon. Prevention of Pressure Injuries Protocol dated 01/2018: The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions on the risk factors. Protocol identifies ankles as one of the most common sites of pressure injury. Pressure can also come from splints, casts, bandages, and wrinkles in the bed linen. If pressure injury is not treated when discovered, they quickly get larger, become very painful for the resident, and often become infected. A pressure injury risk assessment will be completed upon admission, and then weekly times 3 weeks, with each additional assessment; quarterly, annually and significant changes. Skin will be assessed for the presence of developing pressure injuries on a weekly basis or more frequently if indicated. Because a resident at risk can develop a pressure injury within 1 to 4 hours of the onset of pressure, the at-risk resident needs to be identified and have interventions implemented promptly attempt to prevent pressure ulcers. The admission evaluation helps define those initial care approaches and interventions. Monitor the placement of splints, immobilizers, and casts to ensure they are not placing friction on the resident's skin. Documentation requirements include the signature and title (or initials) of the person recording the data. Braden Scale assessment tool is necessary when providing pressure ulcer risk assessment.

Based on observation, interview and record review, the facility failed to contain oxygen equipment (nebulizer mask) per facility's policy. This failure affected one residents (R6) reviewed for oxygen equipment, in total sample size of 11 residents.Findings include: R6's face sheet shows that R6 has diagnosis which include but is not limited to anemia, type 2 diabetes mellitus with hyperglycemia.On 02/09/26 at 11:07 am, R6 was observed sitting in a wheelchair in her room. R6's nebulizer mask was not in use and not contained. R6 explained that she had the flu and COVID 19 about a week ago and that staff will give her the nebulizer machine and mask daily when she feels short of breath. On 02/09/26 at 11:10 am, Surveyor brought this observation to V3 (Quality Director, Infection Preventionist). V3 stated that the nebulizer mask should be contained in a bag when not in use for infection control. V3 also explained that the nebulizer mask is contained in a bag when not in use to avoid contamination. V3 then explained that R6 was recently positive for COVID 19 and was last isolated with contact/droplet precautions for COVID 19 about one week ago. R6's Physician Order Sheet (POS) shows active order dated 2/1/26 shows that R6 has orders for DuoNeb inhaler solution every shift 1 vial every shift for congestion inhalation. The facility's policy dated 2/2025 and titled Administering Medications Through a Small Volume (Handheld) Nebulizer documents, in part: Purpose: The purpose of this procedure is to safely and aseptically administer aerosolized particles of medication into the residents airway . Steps in the Procedure: H. When equipment is completely dry, store in a plastic bag with the residents name and the date on it.

Based on observation, interview, and record review the facility failed to perform hand hygiene and don the required Personal Protective Equipment (PPE) when providing care for three residents who required Enhanced Barrier Precautions (EBP). These failures affected three residents (R1, R10 and R11). Findings include: The facility's document titled Enhanced Barrier Precaution shows that R1, R10 and R11 require EBP at the facility. 1.) R1's face sheet without a listed date document in part that R1 was admitted on [DATE] with diagnosis of: Urinary tract infection, retention of urine, acute kidney failure, dementia, need for assistance with personal care, dysphagia, heart failure, bacteremia, Escherichia coli, weakness. R1's Minimum Data Set, dated [DATE] documents in part; section C (cognitive patterns) documents in part that R1 has a score of 3 which means that R1 has severe cognitive impairment. R1's care plan dated 01/12/2026 documents in part; R1 is at risk for acquiring or transmitting infection due to Foley catheter and wound. R1 is placed on contact precaution for ESBL E-COLI in urine ( resolved);02/02/2026: R1 is on enhanced barrier precaution (EBP) due to foley catheter, wound; Goal: prevent transmission of infection.[Intervention: staff to wear gowns and gloves on high contact areas].02/02/2026 R1 has altered elimination related to indwelling foley catheter; Goal: R1 will be free from signs and symptoms of urinary tract infection.[Intervention: staff to provide indwelling catheter care per facility protocol]. On 02/09/2026 at 10:50am, V6 (Certified Nursing Assistant/CNA) came into the room of R1 and provided morning care to R1. V6 provided morning care to R1 without Personal Protective Equipment (PPE) gown on. V6 stated she was supposed to have on a gown prior to providing care to R1 but forgot to put the gown on. V6 stated the purpose of PPE and wearing a gown is to protect herself from any infection. V6 states the reason R1 has EBP precautions is because R1 has a foley catheter in place. On 02/09/2026 at 10:53 am, V8 (Licensed Practical Nurse/LPN) stated when staff are working in an EBP room the staff need to wear gown and gloves when providing ADL (Activities of Daily Living) care to prevent spread of infection, gown protects the staff from spreading infection from room to room. On 02/09/2026 V5 (Quality Director Infection Preventionist/Registered Nurse) stated staff providing direct patient care such as changing diaper, linen, transferring a patient or providing incontinent care, wound care dressings, staff handling indwelling medical device should be wearing PPE to prevent the spread and transmission of the infection. 2.) R10's face sheet shows that R10 has diagnosis which includes but not limited to basal cell carcinoma of skin of unspecified parts of face. R10's Physician Order Sheet (POS) dated 10/6/25 shows that R10 has orders for Enhanced Barrier Precautions due to a wound. On 2/9/26 at 11:30 am, observed R10's room with a sign on the door that read Enhanced Barrier Precautions: Everyone must: clean their hands, including before entering and when leaving the room. Providers and staff must also wear gloves and a gown for the following high contact resident care activities. V5 (CNA) was observed without wearing a gown and performing ADL care (incontinence care) to R10. Surveyor questioned V5 regarding R10's EBP and V5 stated, EBP means that I should be wearing a gown and gloves when I am providing her (R10) care. I didn't have a gown on. I was moving too fast and forgot to put a gown on. V5 then explained that residents who are on EBP require a gown and gloves when providing care to protect the residents and staff from spreading an infection. 3.) R11's face sheet shows that R11 has diagnosis which includes but is not limited to anxiety, unspecified severe protein-calorie malnutrition, and Fracture of left pubis, subs for fracture with routine heal. R11's Physician Order Sheet (POS) dated 2/4/26 shows that R11 has orders for Enhanced Barrier Precautions due to presence of wound every shift. R11's care plan dated 2/5/26 documents in part: R11 is a risk for tor acquiring or transmitting infection due to wound . A. Follow established infection prevention protocol including Enhanced Barrier Precautions. On 02/09/26 at 11:26 am, observed R11's room with a sign on the door that read Enhanced Barrier Precaution: Everyone must: clean their hands, including before entering and when leaving the room. Providers and staff must also wear gloves and a gown for the following high contact resident care activities. R11 was observed in bed awake, being assisted with feeding for R11's lunch meal by V4 (CNA). Surveyor did not observe V4 wearing a gown while assisting R11 with Activities of Daily Living (ADL) feeding and without performing hand hygiene when V4 left R11's EBP room. When surveyor brought this observation to V4, she stated (As she continued to walk down the unit), She (referring to R11) gets an early lunch tray. I don't have to wear a gown while I'm in her room feeding her. On 2/9/26 at 1:39 pm, V3 (Quality Director/ Infection Preventionist/Registered Nurse) stated that she is the facility's infection preventionist for last year at the facility. V3 then stated that residents are placed on Enhanced Barrier Precaution (EBP) as a form of transmission-based precaution for those residents with history of MDRO (Multi Drug Resistant Organism). V3 further explained that residents with EBP have assistive medical devices such as an indwelling medical device, IV (intravenous) access, eternal feeding, tracheostomy and wounds. V3 then stated if staff perform direct patient care such as changing diapers, linen, transferring a patient, providing incontinence care, the nurse is performing wound care dressing or staff is handling indwelling medical device, staff are required to use PPE (gown and gloves) as well as perform hand hygiene. V3 further stated that PPE required for EBP is hand hygiene, donning a gown and gloves before patient care and in between patient care if gloves are visibly soiled. V3 then explained that during dining if the resident is on EBP and being assisted with feeding in the resident's room, the staff should be wearing PPE (gown and gloves) and perform hand hygiene before entering and exiting the EBP room. V3 stated that PPE is utilized with EBP residents as a barrier for the staff and patient to prevent spread of infection and particularly if there is a colonization of bacteria found with the resident. V3 finally explained that there will be a potential for break of chain of infections and staff can be a carrier of infection from one patient to another if the staff does not perform appropriate hand hygiene and don appropriate PPE when caring for EBP resident. V3 explained that staff are in-serviced regarding EBP upon hire, annually, and during direct observation from staff observed not following the proper precautions. The facility's document dated 6/2025 and titled Standard and Transmission-Based Precautions documents, in part: Policy: It is our policy to take appropriate precautions to prevent transmission of pathogens, based on the pathogens' model of transmission . Enhanced Barrier Precautions: A. Each community will fully implement enhanced barrier precautions EBP in accordance with CMS regulatory requirements. EBP in addition to standard in contact precautions, shall be implemented during high contact resident care activities when caring for residents an increased risk for acquiring and/or transmitting a multi-drug-resistant organism (MDRO) such as a resident with wounds, indwelling medical device and residents with colonization with an MDRO. B. EBP is an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply.

Based on observation, interview, and record review the facility failed to ensure that food is labeled with a date the food was opened and a date the food expires. These failures have the potential to affect 131 residents living in the facility.Findings include: On 01/14/2026 at 10:22 AM, during an annual and licensure certification, surveyor performed an inspection of the facility's dry food storage room, which was conducted with V5 (Dining Services Director). Surveyor found a bag of hot dog buns that were opened and not labeled with an open date and not labeled with an expiration date. Surveyor found a bag of hamburger buns that were opened and not labeled with an open date and not labeled with an expiration date. Surveyor found a bag of white bread that was opened and not labeled with an open date and not labeled with an expiration date. On 01/14/2026 at 10:23AM, V5 stated, The foods that are opened should be labeled with a date it was opened and a date that the food expires. Food and Supply Storage Policy (revised 01/2024) states in part: All food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. Cover, label and date unused portions and open packages.

Based on interview and record review, the facility failed to refer a resident (R11) who was later identified with a serious mental disorder or related condition to the appropriate state-designated authority for a Level II PASARR (Pre-admission Screening and Resident Review) evaluation and determination for one out of 26 residents reviewed for PASARRs.Findings include: R11's Profile Face Sheet documents in part an original admit date of 10/10/2024. V30 (Admissions Director) submitted R11's Level I PASARR (Pre-admission Screening and Resident Review) dated 10/10/2024. The outcome documents in part no Level II required because R11 had no severe mental illness, intellectual disability, or related conditions. V30 elected no mental health diagnoses known or suspected and no mental health medications for R11. R11's current Profile Face Sheet, however, documents in part diagnoses including but not limited to major depressive disorder, recurrent severe without psych features; generalized anxiety disorder; post-traumatic stress disorder; and adjustment disorder with mixed anxiety and depressed mood. R11's physician orders document in part orders for Remeron (antidepressant) and Escitalopram (antidepressant). The surveyor asked facility if they have a new Level I or Level II for R11. On 1/14/2026 at 2:46 PM, V1 (Executive Director) stated facility did not resubmit R11 for a Level II PASARR. During a follow-up interview at 3:34 PM, V1 stated V30 (Admissions Director) and V31 (Social Service) submit to the state-designated authority but did not resubmit for R11. V1 stated facility has not been resubmitting for Level II PASARRs for new mental health diagnoses and staff were not aware it was part of the requirements. Facility's PASRR (Pre admission Screening & Resident Review) policy (last revised 04/2025) does not document in part a process for resubmitting for a Level II PASARR for residents who are later identified with newly evident or possible serious mental disorder, intellectual disability, or a related condition.

Based on observation, interview and review of record, the facility has the following failures related to pharmaceutical services: the facility failed to follow their policy and store controlled substances in a safe and secure manner and ensure an accurate controlled drug form for R129. This was true for 2 out of 4 medication carts reviewed for medication storage. Facility also failed to administered medicine properly by leaving medication at the bedside. Failed to administer medications as ordered by physician. These failures apply to 8 residents (R24, R57, R61, R67, R93, R102, R129, R143) receiving pharmaceutical services in the facility that may affect their healthcare needs.Findings include: 1.) On 1/13/2026 at approximately 11:35 AM, a medication cart was outside of R52's room. R52's room door was closed. The nurse responsible for the medication cart was not present. The medication cart's lock was not engaged. Surveyor was able to open medication drawers including the drawer that contained the locked narcotic bin. Surveyor also noted a set of keys with a blue spring keychain on top of the medication cart. On 1/13/26 at 11:39 AM, V7 (Nurse) exited R52's room. V7 stated [V7] was responsible for the mediation cart. V7 stated [V7] was applying a cream to R52 and needs to administer Tylenol. V7 grabbed the keys that were on top of the medication cart and placed them inside scrub pocket. V7 donned personal protective equipment, went back inside R52's room, and closed the door. V7 did not engage the medication cart's lock. On 1/13/26 at 11:46 AM, V7 exited R52's room. Surveyor reviewed V7's medication cart with V7. V7 stated only nurses should have access to medication carts. V7 stated the nurse assigned to the cart carries the specific keys associated with the cart. V7 verified it was the same keys with the blue spring keychain that were left on top of the cart unattended. V7 demonstrated that the key to the medication cart and the narcotic bin were among the keys on the keychain. Narcotic bin had multiple controlled medications including Tramadol and Morphine. 2.) On 1/14/2026 at 10:14 AM, surveyor reviewed the 2B and 2C medication cart with V11 (Agency Nurse). V11 stated the cart contained medications for about 15 residents. At 10:22 AM, surveyor reviewed the narcotic count with V11. R129's Controlled Drug Receipt/Record/Disposition Form for clonazepam (Brand Klonopin – a controlled substance) documents in part that there should be 26 tablets left in the medication blister pack. However, R129's clonazepam blister pack contained 25 tablets. V11 stated V11 did not administer the medication to R129 because it is an evening medication. V11 stated conducting the narcotic count last night with the outgoing nurse during shift change, but did not note that the count was off. V11 stated we did the count so not sure if we went too fast or what. On 1/15/2026 at 10:40 AM, V3 (Director of Nursing) stated the facility investigated the issue and found that the evening nurse charted administrating the clonazepam to R129 in the electronic medical record but failed to put it down on the narcotic logbook. V3 stated nurses should document in the computer and in the narcotic book immediately after administration. Facility's Storage and Labeling of Medications policy (last revised 11/2024) documents in part: The community shall store all drugs and biologicals in a safe, secure, and orderly manner appropriately. All drugs and biologicals will be stored in locked compartments (i.e. medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. Only authorized personnel will have access to the keys to locked compartments. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. Facility's Controlled Substances policy (last revised 06/2020) documents in part: The community shall comply with laws, regulations, and other requirements related to handling, storage, disposal, and documentation of schedule II-V and other controlled substances. Only authorized nursing and/or pharmacy personnel shall have access to Schedule II controlled drugs maintained on premises. Keys to controlled substance containers shall be on a single key ring that is different from any other keys. The associate administering medications, who confirmed count at the start of the shift, will maintain the keys to controlled substance containers. Keys are passed from associate to associate at the time of count. Associates to count controlled medications at the end of each shift. The associate coming on duty and the associate going off duty are to make count together. The number total number of controlled substances are counted and confirmed. Changes that occurred to the count are documented on the shift to shift count sheet. The leaving associate will read the count for each controlled substance. The oncoming associate will compare to the individual controlled substance. They must document and report any discrepancies to the Director of Nursing Services, or designee. The associate ending their shift is not to leave until Director of Nursing, or designee, gives approval. 3.) On 01/13/2025 at 12:01 PM, R102 was seen laying on her bed alert and able to express her needs well. R102 was seen with medication cup on her bedside table with white oval tablet inside. R102 stated I don't know what is that medication they must have placed it there while I was sleeping. R102 expressed that she was not satisfied with current services related to call light that was seen on the floor unreachable to R102. R102 stated, you stated that I have medicine. Then took the medication cup, picked up the white tablet medicine, and put it inside her mouth. R102 was asked what is that medicine she just took. R102 replied, I don't know, I just take it even when I don't know. V9 (Registered Nurse) at the nurse station stated that she is assigned to R102. V9 said that medicine should not been left at the bedside. 4.) R57 an [AGE] year-old resident in the facility from 12/12/2025 to 12/29/2025. R57 was admitted with medical diagnosis for congestive heart failure. R57 was ordered by the physician to receive Bumetanide (Bumex) 1MG to take three (3) tablets for a total of 3 MG. Bumetanide (Bumex) 3 MG scheduled to take three (3) times a day on 12/12/2025 upon admission. Changed to two (2) times a day from 12/13/2025 to 12/17/2025. Changed to once daily from 12/20/2025 to 12/22/2025 and increased back to two (2) times a day from 12/22/2025 to 12/29/2025 when R57 was discharged . R57's weight increased significantly from 115 LBS on 12/21/2025 to 127 LBS on 12/22/2025 an increase of 12 LBS a single day. R57's weights maintained after significant increase 126.4 LBS on 12/23/2025, 129 LBS on 12/24/2025, 127.3 LBS on 12/26/2025, 125.7 on 12/27/2025 and 12/28/2025. R57's medication administration record shows that facility did not document Bumetanide (Bumex) 3 MG as being administered to R57 twice on 12/26/2025, once on 12/27/2025 and once on 12/28/2025 in accordance with physician order. Per nursing notes dated 12/29/2025, it documents that R57 was transferred to the hospital due to requests by V28 (Family of R57) expressing concern that R57 may be experiencing fluid overload. R57 was admitted to the hospital for observation. Per facility pharmacy Bumetanide (Bumex) medications are indicated for the treatment of edema (excessive fluid retention) associated with congestive heart failure, hepatic and renal disease, including nephrotic syndrome. HEALTHIER LIVING WITH HEART FAILURE Managing Symptoms and Reducing Risk by American Heart Association dated 2025 reads: The effects of heart failure can be felt throughout the body. You're likely to have one or more of the following symptoms: EDEMA If you have heart failure, your heart doesn't pump blood with enough force. This means that not enough blood is pumped out of the heart with each heartbeat. Then, because the heart isn't emptying as it should, blood returning from the body can't enter the heart and backs up in the veins. This forces fluid from the blood vessels into other tissues, causing swelling (edema). Edema can occur in the feet, ankles, legs and fingers, as well as in the abdomen and in other tissues and organs. As a result, weight gain is common. MEDICATIONS COMMONLY USED TO TREAT HEART FAILURE The following are some of the most common medications used to treat heart failure: Diuretics furosemide, bumetanide, torsemide, hydrochlorothiazide Lasix, Bumex, Demadex, HCTZ. Reduce excess fluids and salt to decrease the buildup of fluid in the lungs and other parts of the body, such as the ankles, legs and abdomen. Make it easier for the heart to pump blood. 5.) Medication Administration Records for December 2025 and January 2026 were reviewed for R61, R67, R143, R93 and R24 residents have multiple medications that were not documented (initialed/signed) as being administered. On 01/14/2026 at 02:26 PM, V3 (Director of Nursing) stated that medication needs to be administered by physician order. Nurses need to document that medicine was administered right after giving medication on the eMAR (Medication Administration Record) and it should not be left blank. When there is no documentation, medication cannot be proven as administered. Nurses are not supposed to leave medication at the bedside. Nurses need to stay with the resident until resident swallows the medication. Documentation of Medication Administration policy dated 12/2025: The community will maintain a medication administration record to document medications administered. A nurse or certified medication tech shall document the medication administered to each resident on the resident's medication administration record (MAR). Administration of medication to be documented after it is given. Administering Medication policy dated 12/2025: Medication shall be administered in a safe and timely manner, and as prescribed. Only persons that are licensed or permitted by this State to prepare, administer and document the administration of medications. The individual administering the medications to document on the MAR or eMAR after giving each medication and before administering the next ones.

Based on observation, interview, and record review, the facility failed to follow call light policy and procedure on accessibility of call light for 1 out of 1 resident (R102) for a total sample of 26 residents reviewed for environment. Findings include: R102 is a [AGE] year-old resident of the facility. R102 was admitted on [DATE] due to fracture of neck of femur and right hip pain. R102's cognition is intact based on brief interview of mental status done on 12/29/2025 with perfect score of 15. R102 needs substantial or maximal assistance for bed mobility transfer and does not ambulate. On 01/13/2025 at 12:01 PM, R102 was seen laying on her bed alert and able to express her needs well. R102 said that she came to the facility about 2 and a half weeks ago for hip replacement and was doing rehabilitation or therapy. R102 stated that she cannot leave her bed because of her surgery and needs facility staff to help her with her needs. R102 stated that it bothers her so much that it takes facility staff three (3) hours to respond with her call light. And her (R102) call light was unreachable most of the time because it is not attached to the wall where she can reach it. Writer and R102 were trying to locate the call light that was seen on the floor 2 to 3 meters away from R102. R102 said, It is kind of sad, soaked with wet diapers for 3 hours. I even know what's going on. I pity those that do not know what is happening. On 01/13/2026 at 01:05 PM, V26 (Certified Nursing Assistant) was seen inside R102's room from the hallway. R102's call light was still visible on the floor when V26 came out. V26 was asked in the hallway if R102 can use her call light or within reach. V26 replied yes. V26 went back to R102's room, found the call light on the floor, picked it up and clipped it on the left side of R102's linen. V26 went out of the room and stated that R102's call light was not reachable that it needs to be clipped on resident's gown, cloth or linen because it needs to be reachable. On 01/14/2026 at 02:26 PM, V3 (Director of Nursing) stated that nursing staff need to ensure that the call light always within reach to attend to resident's needs. Answering the Call Light policy and procedure dated 12/2017:The purpose of this procedure is to respond to the residents' requests and needs. The community should be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to an associate or to a centralized associate work area. General guidelines require that when resident is in bed or confined to a chair be sure the call light is within reach of the resident. Answer the call light as soon as possible.

Based on observation, interview and review of record, the facility failed to meet quality of care of professional standards related to pharmaceutical services for 2 (R57 and R61) out of 26 residents in the sample reviewed for quality of care. Findings include: 1.) R61 is a [AGE] year-old resident, with diagnosis of type 2 diabetes mellitus. R61 was admitted to the facility on [DATE]. R61 started with tablet medication for diabetes Metformin 500 MG 1 tablet twice a day from 12/17/2025 to 12/18/2025. On 12/18/2025, Metformin 500 MG was changed to Glimepiride 4 MG schedule to take 1 tablet once daily. Per Medication administration record Glimepiride 4 MG was not documented as administered on 12/27/2025, 12/28/2025 and 01/07/2026. R61's MAR (Medication Administration Record) does not document blood sugar results that it was checked per physician order on 12/23/2025, 12/26/2025, 121/27/2025, 12/28/2025, 01/02/2026, 01/06/2026 and 01/11/2026. R61's blood sugar result was increasing reaching more than 300 starting 01/10/2026. On 01/12/2026 and 01/13/2026, R61 was ordered to receive single dose five (5) units of Humalog Lispro insulin. R61's Glimepiride increased from 4 MG to 5 MG. On 01/14/2026, R61 received an order from the physician to monitor blood three (3) times per day with insulin administration depending on blood sugar result. On 01/14/2026 at 10:05 AM during medication administration review, V25 (Registered Nurse) administered two (2) units of insulin Humalog Lispro to R61 via subcutaneous injection did not perform blood sugar check stated that it was checked earlier with 200 results. Management of Diabetes in Long Term Care and Skilled Nursing Facilities: A Position Statement of the American Diabetes Association dated 02/2016: Diabetes are more common in older adults, has a high prevalence in long-term care (LTC) facilities and is associated with significant disease burden and higher cost. Framework for considering diabetes management goals for long term care includes glucose monitoring or blood sugar check with monitoring frequency based on complexity of regimen and risk of hypoglycemia. Under advantages, disadvantages, and caveats in using glucose-lowering agents in LTC population. Insulin is at a high risk for hypoglycemia, especially due to irregular eating patterns. 2.) R57 an [AGE] year-old resident in the facility from 12/12/2025 to 12/29/2025. R57 was admitted with medical diagnosis for congestive heart failure. R57 was ordered by the physician to receive Bumetanide (Bumex) 1MG three (3) tablets for a total of 3 MG three (3) times a day on 12/12/2025 upon admission, two (2) times a day from 12/13/2025 to 12/17/2025, once daily from 12/20/2025 to 12/22/2025 and increased back to two (2) times a day from 12/22/2025 to 12/29/2025 when R57 was discharged . R57's weight increased significantly from 115 LBS on 12/21/2025 to 127 LBS on 12/22/2025 an increase of 12 LBS a single day. R57's weights maintained after significant increase 126.4 LBS on 12/23/2025, 129 LBS on 12/24/2025, 127.3 LBS on 12/26/2025, 125.7 on 12/27/2025 and 12/28/2025. R57's medication administration record shows that facility did not document Bumetanide (Bumex) 1MG three (3) tablets for a total of 3 MG as being administered to R57 twice on 12/26/2025, once on 12/27/2025 and once on 12/28/2025. Per nursing notes dated 12/29/2025, it documents that R57 was transferred to the hospital due to requests by V28 (Family of R57) expressing concern that R57 may be experiencing fluid overload. R57 was admitted to the hospital for observation. Per facility pharmacy Bumetanide (Bumex) medications are indicated for the treatment of edema (excessive fluid retention) associated with congestive heart failure, hepatic and renal disease, including nephrotic syndrome. HEALTHIER LIVING WITH HEART FAILURE: Managing Symptoms and Reducing Risk by American Heart Association dated 2025 reads: The effects of heart failure can be felt throughout the body. You're likely to have one or more of the following symptoms: EDEMA If you have heart failure, your heart doesn't pump blood with enough force. This means that not enough blood is pumped out of the heart with each heartbeat. Then, because the heart isn't emptying as it should, blood returning from the body can't enter the heart and backs up in the veins. This forces fluid from the blood vessels into other tissues, causing swelling (edema). Edema can occur in the feet, ankles, legs and fingers, as well as in the abdomen and in other tissues and organs. As a result, weight gain is common. MEDICATIONS COMMONLY USED TO TREAT HEART FAILURE The following are some of the most common medications used to treat heart failure: Diuretics furosemide, bumetanide, torsemide, hydrochlorothiazide Lasix, Bumex, Demadex, HCTZ. Reduce excess fluids and salt to decrease the buildup of fluid in the lungs and other parts of the body, such as the ankles, legs and abdomen. Make it easier for the heart to pump blood. On 01/14/2026 at 02:26 PM, V3 (Director of Nursing) stated that the expectation for nurses to follow and implement physician order. On 01/15/2026 at 10:40 AM, V3 stated that medications that are scheduled to be given before meals need to be scheduled at 06:00 AM. And those medications that are scheduled with meals must align with breakfast time. V3 stated she will address with nurses why medication was given at around 10:00 AM not during breakfast. Per mealtime schedule, breakfast comes at 07:45 AM. Facility's policy and procedure on Administering Medication dated 12/2025, requires that medication shall be administered in a safe and timely manner, and as prescribed.

Based on observation, interview, and review of record, the facility failed to follow the facility's medication administration policies. The facility also failed to follow physician order instruction during medication administration of 1 out of 6 residents (R61). There were thirty-one (31) opportunities with 6 errors resulting in 19.35% error rate. Findings include: On 01/14/2026 at 09:36 AM with V25 (Registered Nurse) at the medication cart. V25 prepared the following medicines that were labeled for R61: Bumetanide 1 MG Oral Tablet administered orally.Pioglitazone 30 MG Oral Tablet administered orally.Ferrous Sulfate 325 MG Oral Tablet administered via mouth.Finasteride 5 MG Oral Tablet administered orally.Vitamin C 500 MG Tablet administered orally.Multivitamins tablet administered orally.Aspirin 81 MG Oral Tablet administered via mouth.Folic Acid 1 MG Oral Tablet administered via mouth.Metoprolol Succinate 25 MG Extended-Release Oral Tablet administered orally.Carbidopa 25 MG / Levodopa 100 MG Oral Tablet administered orally.Senna-S 8.6 MG - 50 MG administered orally.Glimepiride 4 MG Oral Tablet administered orally.Albuterol 0.83 MG/ML Inhalation Solution administered through nebulizer inhalation.Insulin lispro 100 UNT/ML Cartridge [Humalog] administered through subcutaneous injection. V25 placed all tablet form medicines inside a 30 ML medication cup then poured into a larger plastic cup. V25 then took apple sauce in an open container using a plastic spoon scoop 3 spoons full of apple sauce into the plastic cup where 12 tablets are located. V25 then mixed apple sauce with 12 tablets went inside R61's room where V24 (Family of R61) was at the bedside. V25 then multiple times with plastic spoon scoop medication tablets with apple sauce inside R61's mouth. R61 was unable to tolerate swallowing. V24 told V25 that R61 medication needs to be crushed for R61 to tolerate swallowing. V25 replied that some medication of R61 cannot be crushed. R61 spit out two (2) tablets that fell on the bed. V25 put it on the cup and left the room while R61 was still swallowing those medications inside his mouth. V25 stated that the two (2) tablets were Vitamin C and Aspirin although tablets partially dissolved then threw it on sharp container. R61 currently has an order from physician to crush appropriate medication. V25 went to her medication cart in the hallway, threw two (2) tablets inside sharp container. V25 opened a package took out nebule of Albuterol 0.83 MG/ML Inhalation Solution. Went inside R61's room where V24 called her attention that R61 still spitting medication tablets. V24 picked up a tablet on the bed with her finger then put it back inside R61's mouth. V25 then went on the bedside of R61 that was leaning to the right both head and body. V25 took nebulizer mask connected with a tubing to a nebulizer machine. Turn nebulizing chamber counterclockwise to open poured liquid medicine inside the nebule and closed nebulizing chamber tuning clockwise. V25 placed nebulizer mask covering R61's mouth and nose while R61 was still in a leaning position to the right on both head and body. V25 turns on nebulizing machine for 15 minutes using her cell phone as a timer. About 8 minutes during nebulization mist cannot be seen going out of R61's mask although liquid medication is still visible inside nebulizing chamber. R61 was in the same position for the full duration of administration. V25 took nebulizer mask out of R61's face. Open nebulizing chamber poured liquid medicine on the sink and rinse it with water. V25 was made aware that there was a lot of medicine left in the nebulizing chamber because of R61's position. At around 10:05 AM V25 (Registered Nurse) administered two (2) units of insulin Humalog Lispro to R61 via subcutaneous injection did not perform blood sugar check stated that it was checked earlier with 200 results. On 01/14/2026 at 02:26 PM, V3 (Director of Nursing) stated that proper medication administration for the nurse not to leave resident until sure that resident received all their medicine. After nurses give medicine, residents will be asked to open their mouths to make sure they swallow all their medicines. V3 stated that during medication administration by nebulizer treatment, residents need to be semi-Fowler (laying on his/her back, head elevated) and needs to be vertical. On 01/15/2026 at 10:40 AM, V3 stated that medications that are scheduled to be given before meals need to be scheduled at 06:00 AM. And those medications that are scheduled with meals must align with breakfast time. V3 stated she will address with nurses why medication was given at around 10:00 AM not during breakfast. Reviews of R61's medications that were not given at the right time are as follows:Glimepiride 4 MG Oral Tablet - new order is for 5 MG and physician order instructed to be administered with meals. R61 has high blood sugar results on 01/10/2026, 01/12/2026 and 01/13/2026. Albuterol 0.83 MG/ML Inhalation Solution - nebule inside the medication not fully administered due to resident positioning, still medication left inside nebulizing chamber. Insulin lispro 100 UNT/ML Cartridge [Humalog] - physician order instructed to give with meals. Pantoprazole 40 MG Oral Granules - 1 tablet by mouth every day before breakfast was scheduled after breakfast scheduled at 09:00 AM. Per mealtime schedule breakfast comes at 07:45 AM. Administering Medications policy and procedure dated 12/2024 reads: Medications shall be administered in accordance with the orders and within the allowable time frame per best practice / regulatory guidelines (60 minutes before the due time and 60 minutes after the due time). Following this procedure will make Pantoprazole 40 MG earliest administration at 08:00 AM which is after mealtime breakfast schedule. Two unidentified tablets spit out by R61. Administering Oral Medications policy and procedure dated 12/2025: The purpose is to provide guidelines for the safe administration of oral medications. Proper procedure is to allow residents to swallow oral tablets or capsules at his or her comfortable pace. If resident cannot hold his or her own medications, place the cup near the lips and gently introduce each medication one at a time, followed by a sip of water. Do not rush the residents. Remain with the resident until all medications have been taken. Administering Medications Through a Small Volume - Handheld - Nebulizer dated 04/2025: Procedure on administering treatment instructs healthcare providers to place resident into semi-Fowler_position, keep nebulizer vertical during treatment and administer therapy or medicine until gone.

Based on observation, interview, and record review, the facility failed to follow their policy and store all drugs and biologicals in a safe and secure manner. This was true for 2 out of 4 medication carts and 1 out of 4 medication rooms reviewed for medication storage. Findings include: On 1/13/2026 at approximately 11:35 AM, a medication cart was outside of R52's room. R52's room door was closed. The nurse responsible for the medication cart was not present. The medication cart's lock was not engaged. Surveyor was able to open medication drawers. Surveyor also noted a set of keys with a blue spring keychain on top of the medication cart. On 1/13/26 at 11:39 AM, V7 (Nurse) exited out of R52's room. V7 stated [V7] was responsible for the mediation cart. V7 stated the medication cart contains medications for 22 residents. V7 stated [V7] was applying a cream to R52 and needs to administer Tylenol. V7 grabbed the keys that were on top of the medication cart and placed them inside scrub pocket. V7 donned personal protective equipment, went back inside R52's room, and closed the door. V7 did not engage the medication cart's lock. On 1/13/26 at 11:46 AM, V7 exited R52's room. Surveyor reviewed V7's medication cart with V7. V7 stated only nurses should have access to medication carts. V7 stated the nurse assigned to the cart carries the specific keys associated with the cart. V7 verified it was the same keys with the blue spring keychain that were left on top of the cart unattended. On 1/13/26 at 11:58 AM, V7 escorted surveyor to the clean utility room inside the dementia, locked unit. V7 stated staff including CNAs (Certified Nursing Assistants) and unlicensed staff have access to the clean utility room. V7 stated only medications in the clean utility room are in the locked refrigerator. However, during observations, surveyor found an unlocked cabinet above the sink. Inside there were medications in individual packets. Medications included but were not limited to Losartan, Metoprolol Extended Release, Potassium Chloride, and Tylenol. There was also a small floral reusable bag with multiple medication bottles belonging to R144. There was a total of 15 medication bottles with medications including but not limited to Metoprolol, Tamsulosin, Gabapentin, and Eliquis. V7 did not know if R144 remained in the facility. V7 stated the pharmacy usually responds to requests for deliveries and pick-ups within 24 hours. V7 did not know why the medications were in the cabinet. At approximately 12:03 PM, V10 (Nurse) walked into the clean utility room. V10 stated R144 was no longer a resident of the facility. V10 did not know why the medications were in the cabinet. R144's Profile Face Sheet documents in part that R144 discharged from the facility on 1/16/2025. A wound cart was also in the clean utility room. The wound cart was unlocked. V7 and surveyor were able to open the drawers in the wound cart. There were multiple ointments and creams in the first drawer. V7 stated they are prescribed medicated creams and ointments for residents who have wounds. On 1/13/2026 at 1:57 PM, surveyor reviewed first floor 1A medication cart with V8 (Nurse). In the second drawer, there was an open vial of Lantus for R79. The discard date was for 1/08/2026. V8 stated all nurses are responsible for reviewing their medication carts with night nurses specifically responsible for taking out expired medications. In the second drawer, there was also a Humalog Kwikpen for R145. It did not have an open date. The bag had a label that read refrigerate until opened. V8 reviewed R145's medication administration record. V8 stated R145 has a sliding scale with the insulin and has not needed it. V8 stated the medication should have been in the fridge if it was not opened. Facility's Storage and Labeling of Medications policy (last revised 11/2024) documents in part: The community shall store all drugs and biologicals in a safe, secure, and orderly manner appropriately. All drugs and biologicals will be stored in locked compartments (i.e. medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. Only authorized personnel will have access to the keys to locked compartments. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. All medications requiring refrigeration are stored in refrigerators located in the pharmacy and at each medication room. Temperatures are maintained within 36-46 degrees F. Unused Medications: The medication/treatment cart and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. These medications are destroyed in accordance with community/pharmacy processes.

Based on observation, interview and record review the facility failed to ensure PPE (Personal Protective Equipment) was properly disposed of before the staff member exited one (R42) resident on EBP (Enhanced Barrier Precautions) room and failed to ensure PPE was donned when changing the linen for one (R69) resident on EBP. Findings Include: R42 has diagnosis not limited to Cellulitis of Right lower Limb, Lymphedema and Sepsis.R42's Physician's Orders document in part: Midline Insertion, Wound Care Right Knee and Wound Care Right Lower Leg. Enhanced Barrier Precautions, IV (Intravenous) therapy.R42's Care Plan document in part: Pressure Ulcers/Skin Prevention: R42 has right lower extremity cellulitis with open wounds to right lower extremity. Infection and IV's: R42 is on antibiotic therapy for cellulitis on bilateral lower extremities.On 01/13/26 at 11:35 AM V16 (Registered Nurse) exited R42's room with PPE (Personal Protective Equipment) on, doffed the PPE in the hallway, then put the PPE in a hamper located in the hallway. V16 stated R42 is on isolation for a wound. R42 is not COVID, just a precaution. EBP (Enhanced Barrier Precautions) is used for anything on the skin or urinary catheter, they are on barrier precautions. When Doffing PPE I take off the gloves then gown and throw it out. I remove the PPE when outside of the resident's room. The hamper in the hallway is the hamper for PPE. When going in a COVID room I remove all PPE outside of the resident's room. If you remove the PPE inside the room, you will get COVID. 2.) R69 has diagnosis not limited to Metabolic Encephalopathy, Dementia and Adult Failure to Thrive.R69's Physician Orders document in part: Wound Care Sacrum, Enhanced Barrier Precautions.R69's Care Plan document in part: Pressure Ulcer/Skin Prevention: R69 has impaired skin integrity related to Pressure ulcer in sacrum and left buttock excoriation.On 01/13/26 at 11:47 AM V17 (Certified Nursing Assistant/CNA) stated before entering an isolation or an Enhanced Barrier Precaution room, I don the PPE outside the door. Before exiting the resident's room, I remove and discard the gown and gloves inside the resident's room. I dispose the gown and gloves in the garbage inside the resident's room. The hampers in the hallway are the garbage and dirty linen. There is a garbage can inside the resident's room.On 01/13/26 at 11:50 AM V18 (CNA) was observed entering R69's room with linen. V18 did not don PPE, opened R69's door, entered the room then close the door. Surveyor knocked on then opened R69's door and observed V18 making R69's bed. Enhanced Barrier Precaution signage was observed posted on R69's door. V18 exited R69's room. Surveyor asked V18 what type of PPE should have been worn when changing R69's linen. V18 responded when a resident is on EBP a gown and glove should be worn when changing the linen. There is a potential you can be infected and if you come in contact with another resident's, you can give it to them.On 01/14/2026 at 12:15 PM V14 (Quality Director/Infection Preventionist) stated the procedures for donning PPE are hand hygiene, appropriate mask, face shield/goggles, a gown tie it, and the last thing is the gloves. During doffing the gloves are the first to be removed. The expectation before you go out of the resident's room you remove your gown and gloves. The face shield and N95 can be replaced outside the room, and you can do hand hygiene after exiting the room or at the handwash station inside the room. They are to discard the gown and gloves inside the resident's room to avoid cross contamination from outside everything is soiled and should be tied in a bag and placed in the trash bin. At the end of the shift gather all isolation trash, place it in the red bag and take it to the soiled utility room. He hampers in the hallway; one is for soiled linen and one for garbage. We encourage the staff to put the isolation garbage in a red bag and take it to the soiled utility room. EBP depends on medical devices and wounds. My expectation is to wear a gown and gloves for direct patient care, changing linen, assisting residents to the toilet, doing incontinence care, taking care of a urinary catheter or any indwelling medical device, doing wound dressing and taking care of an IV. We consider them as standard precautions. My expectation is to do hand hygiene, put on a gown and gloves as they enter into the resident room to do the care. The purpose for PPE is it protects the resident and staff member as a barrier for exposure to any bodily fluid. R42 has wounds on the legs with weeping and a history of venous stasis on right leg. R69 has a wound stage 3 wound on the sacrum. It is on the EBP signage guidelines that V18 (Certified Nurse Assistant) should have put on a gown and gloves.Policy:Titled Infection Prevention and Control Program revised 06/25 document in part: Policy Statement: 4. The IPCP (Infection Prevention and Control Program) is designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Policy Interpretation and Implementation: B. The objectives of our infection prevention and control policies and practices are to: 1. Prevent, detect, investigate, and control infections in the community; 2. Maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public.Titled Standard and Transmission-Based Precautions revised 06/25 document in part: 4. PPE (Personal Protective Equipment) is removed and discarded other than respirators, upon completing a task before leaving the resident's room or care area. Healthcare personnel have access to and are trained and able to select, put on, remove, and dispose of PPE in a manner that protects themselves and the resident. Enhance Barrier Precautions: B. Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. D.3. Enhanced Barrier Precautions expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs (Multidrug resistant organisms) to staff hands and clothing. 4. Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: e. Changings linens.Titled Procedure: Personal Protective Equipment revised 02/25 document in part: Objectives: A. To prevent the spread of infection. Equipment and Supplies, Donning and Doffing: A. Perform Hand Hygiene. B. [NAME] Gown. E. [NAME] Gloves. Doffing PPE: A. Remove Gloves. C. Remove Gown. E. Discard in Waste Container. F. Perform Hand Hygiene. When to use gloves: 9. When completing high contact activities for resident under Enhanced Barrier Precautions. Removing Gloves: D. Discard the gloves into a designated waste receptacle inside the room. Gowns: B. When gowns are used, they are used once and discarded into appropriate receptacles located in the room in which the procedure was performed. Miscellaneous: H. After completing the treatment or procedure, gowns must be discarded in the appropriate container located in the room. Removing the Gown: F. If the gown is disposable, discard it into the waste receptacle inside the room.Enhanced Barrier Precautions signage indicates everyone must: Clean their hands, including before entering and leaving the room. Providers and staff must also: Wear gloves and a gown for the following High-Contact resident care activities. Changing Linen.

Based on interview and record review, the facility failed to clean and empty a resident's ileostomy bag in a timely manner. The facility also failed to ensure an accurate skin assessment upon admission. These failures affect one (R1) out of three residents reviewed for ostomy care. Findings include: R1's Face sheet documents that R1 was admitted to the facility on [DATE] and discharged on 08/26/2025. On 09/13/2025 at 12:51PM, V4 (Registered Nurse/RN) states R1 was admitted to the facility from the hospital on [DATE]. V4 states she was the nurse assigned to care for R1 on 08/26/2025. V4 states sometime after lunch around 12:30PM, V6 (R1's Family Member) asked the staff to change R1's colostomy bag because it was soiled and full. V4 states V5 (Certified Nursing Assistant/CNA) had begun cleaning R1's body before V4 arrived to R1's room. V4 states then V5 alerted her that while V5 was cleaning on the right side of R1's body, there was a [NAME] of fluids from what appeared to be a surgical wound that was located underneath R1's skin fold. V4 states this surgical wound was not visible unless R1's skin fold was lifted up. V4 states this wound was located on the opposite side of R1's ileostomy site, which was located on R1's left side. V4 states she checked R1's skin assessment and whoever performed R1's skin assessment upon admission, did not document the surgical wound because she did not see it documented on R1's skin assessment. V4 states she then read R1's hospital records and this is how she was made aware of R1's surgical wound on her right side. V4 states she observed there was a very small opening on R1's right lower abdomen and she was not aware that it was there until it began leaking. On 09/13/2025 at 1:52PM, V3 (Business Development Coordinator) states she received an email from V6 (R1's Family Member) addressed to herself and V1 (Administrator). V3 states per V6's email, V6 made concerns related to a skin tear near R1's stoma and R1 having a possible UTI. On 09/13/2025 at 2:20PM, V5 (CNA) states she was assigned to care for R1 on 08/26/2025. V5 states it was around breakfast time, and she was passing trays when she was informed by physical therapy that R1's ileostomy bag needed to be changed. V5 states after passing trays, she went inside of R1's room and saw that R1's ileostomy bag was overflowing and needed to be changed so she informed V4 (RN). V5 states at some point, V6 (R1's Family Member) came to the facility to visit R1. V5 states V6 was located in R1's room and informed her that R1's ileostomy bag needed to be changed. V5 states she does not recall what time it was, but she told V6 that she'll be in to assist R1. V5 states she gathered her supplies and believes it was about 15-20 minutes later when she arrived in R1's room. V5 states she began washing R1's genital area using soap, water, and a towel. V5 states R1's colostomy bag is on the left side of her body and R1 has skin folds. V5 states she then called V4 (RN) because V4 was going to reapply a new ileostomy bag. V5 states V4 took R1's ileostomy bag off and they both worked together to care for R1 because R1's ileostomy bag was over-filled with poop. V5 states she did not pay attention to R1's colostomy bag and does not know what kind of ileostomy bag it was. V5 states she did not clean on the right side of R1's body and she began cleaning on R1's left side around R1's stoma with soap and water. V5 states V4 stepped out of the room and that's when she found that R1 had a slit underneath one of her abdominal folds. V5 states the slit was draining liquid when she pressed R1's stomach. V5 states the slit was located on the right side of R1's stomach. V5 states she then called V4 (RN) back into the room to inform her and V4 came right away. V5 states V6 (R1's Family Member) was riled up and kept asking what is going on, what are you guys doing? On 09/13/2025 at 3:25PM, V2 (Director of Nursing/DON) states she was called by V4 (RN) and made aware of fluid mixed with blood coming from the right side of R1's abdomen. V4 states she was in the facility and went to assess R1 herself. V2 states upon her assessment, there was a slit that appeared to be a surgical wound that was open. V2 states from her understanding, R1 had just had surgery on her ileostomy. V2 states R1's cut was very clean and there were no sutures or ripped wound edges. V2 states clear fluid mixed with blood was leaking out of R1's right side. V2 states she then called the doctor for R1 to be sent to the ER. V2 states R1's slit was in her abdominal folds and at first you cannot see it, but if it is pressed, then it opens up. V2 states the ambulance came to transport R1 to the ER pretty quickly. V2 states she was not made aware that R1 was soiled and had to wait a long time to be changed. V2 states she was not aware of an email communication sent by V6 (R1's Family Member) regarding concerns of R1 waiting 90 minutes to be changed. V2 states she expects the nursing and CNA staff to respond to the needs of the resident as soon as possible. V2 states it is not acceptable for any resident to have to wait an hour and a half to have care rendered. V2 states she is not sure who signed and completed R1's initial skin assessment. V2 states usually, the admitting nurse is the person who performs the initial skin assessment for the residents. V2 states she cannot completely read R1's skin assessment because it is handwritten, and some words are not legible. Email communication dated 08/27/2025 at 10:38AM written by V6 (R1's Family Member) and addressed to V1 (Administrator) and V3 (Business Development Coordinator), documents a concern of R1 being left soiled for an hour and a half.R1's hospital records dated 08/25/2025 documents the following: A transverse incision was made in the right lower quadrant.R1's initial skin assessment dated [DATE] does not document a surgical wound on R1's right lower quadrant.Per R1's nursing progress note dated 08/25/2025, V10 (RN) was the nurse assigned to care for R1 during R1's admission to the facility.An attempt to contact V10 was made on 09/13/2025 at 3:58PM without success, voice message left, awaiting call back. Facility policy dated 12/2017 titled Colostomy/Ileostomy Care documents in part, Preparation A. Review the resident's care plan to assess for any special needs of the resident.

Based on interview and record review, the facility failed to notify the Office of the State Long-Term Care Ombudsman of residents who were transferred or discharged back to the community or to another nursing facility. This failure has the potential to affect residents transferring or discharging out of 124 residents residing in the facility. Findings Include:On 8/17/25 at 9:28 AM, V4 (Social Worker) stated that he emails V13 (Facility Ombudsman) once a week of the list of residents who are hospitalized . V4 stated he does not send notification of the other discharges such as residents who are discharged back to the community because it is not required. Email receipts provided by V4 reviewed and revealed V4 sent the list of hospitalized residents not including other transfers or discharges to V13 on these dates: 8/10/25, 8/1/25, 7/9/25, and 3/27/25.The facility's residents' roster shows 124 residents currently residing in the facility. The facility's Transfer or Discharge, Preparing a Resident for policy and procedure dated 1/25 documents in part: The social worker, or designee, is responsible for: Provide a copy of the notice to the Office of the State Long-Term Care Ombudsman.

Based on observation, interview, and record review, the facility failed to follow their policy of transferring a resident via a mechanical lift. This failure affected 1 (R1) resident reviewed for supervision in the total sample of 3 residents. Findings include: The 06/06/2025 List of Residents on Sit to stand and/or Mechanical Lift transfer include R1. On 06/06/2025, at 11:18 AM, inside R1's room, V12 (Certified Nursing Assistant/CNA) and V13 (Registered Nurse) transferred R1 from the wheelchair to the toilet seat with the use of the sit to stand lift. After sitting R1 on the toilet seat, V13 washed her hands and informed V12 to call her when R1 is done using the toilet. On 06/06/2025, at 11:30 AM, V12 transferred R1 from the toilet seat to R1's wheelchair with the use of the sit to stand lift all by herself. On 06/06/2025, at 11:32 AM, V13 went inside R1's room. V13 asked V12 Why did you not call me? On 06/06/2025, at 11:33 AM, V12 stated we need two-person assist for transfer via the sit to stand lift. I did not wait for her (V13) to assist me because she (R1) is already getting agitated. On 06/06/2025, at 11:55 AM, V13 stated I was in the dining room talking to the sisters. I did not hear her (V12) calling me. The sit to stand lift transfer should be with two-person assist for the safety of the resident. She (R1) has a cognitive deficit. On 06/06/2025, at 2:03 PM, V5 (Director - Quality Management) stated if the intervention is Sit to Stand lift with transfer, the expectation is to implement the intervention for all transfers. The importance of implementing the intervention is to promote safety to residents and staff. On 06/06/2025, at 3:16 PM, V10 (Restorative Nurse) stated when transferring a resident via a Sit to Stand lift, the expectation is to have two staff transferring the resident because it is a machine and that is the regulation and for the safety of the resident and the staff. R1's (undated) Profile Face Sheet documented that R1's diagnoses (include but not limited to) dementia with other behavioral disturbance, hypothyroidism, type 2 DM, and late onset Alzheimer's disease. R1's (04/26/2025) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 02. Indicating R1's mental status as severely impaired. R1's (Start:11/19/2024) care plan documented, in part has potential for falls related to impaired physical mobility, cognitive impairment - poor safety awareness and lack of insight, dementia with behaviors. (05/02/2025) follow transfer therapy/restorative nurse recommendations/plan of treatment: Transfer with Sit to Stand. The 04/13/2025 Nursing Assistant Certified)- LTC (Long Term Care) documented, in part Job Summary: Assists Patients with tending to personal care, activities of daily living, and transfers/ transport. The 06/06/2025 email correspondence with V5 (Director - Quality management) documented, in part The expectation is to follow the facility policies. 1. Transfer using Mechanical lift- by 2 person staff assist. The 06/06/2025 through 06/07/2025 email correspondence with V5 (Director - Quality Management documented, in part The mechanical lifts require 2-person assist for transferring at the facility. We have 2 Sit to stand lift and the mechanical lift. The (01/2024) Safe Lifting and Moving of Patients documented, in part In order to protect the safety and wellbeing of associates and residents, and to promote quality care, this community uses appropriate techniques and devices to lift and move residents. Policy Interpretation and Implementation. A. Resident safety, will be incorporated into goals and decisions regarding the safe lifting and moving of residents. The (04/2024) Using a Portable Lifting Machine documented, in part Purpose: the purpose of this procedure is to help lift resident using a manual lifting device. General Guidelines: Two (2) nursing associates are required to perform this procedure.

Based on interview and record review, the facility failed to provide person-centered discharge plan of care for 5 out 5 residents (R1, R2, R3, R4 and R5) reviewed for care plan. Finding includes: R1 is [AGE] years old, initially admitted in the facility on 02/27/2025. R1 medical diagnosis includes atrial fibrillation, deep vein thrombosis on the right leg, spinal stenosis, radiculopathy lumbosacral region and malaise. R1's cognition based on her BIMS score of 15 dated 03/05/2025. On 04/01/2025 at 10:32 PM, V3 (Ombudsman) stated that R1 and her daughter (V6) had concern about being discharge prematurely. Care plan of R1 was reviewed in relation to discharge planning. Per R1's care plan R1 does not plan to make the community/facility a long-term home that was dated on 02/27/2025. Goal is for R1 to be assisted with plan of stay in the community/facility until discharge is practicable, through the next review period. Interventions includes associates/facility staff will support R1 plan to stay short term. And assist with referrals, as needed, to meet the goals for discharge. It does not have specific information about R1 plan of discharge. Random residents care plan was reviewed including R2, R3, R4 and R5 related to discharge planning: All return to community referral or discharge care planning of R2, R3, R4 and R5 are almost identical, except that residents are categorized as short or long term. On 04/01/2025 at 12:35 PM, V13 (Daughter of R2) said, I do not know any discharge plan. We don't get it straight anywhere here. It is a problem. No social worker talked to me about plan for discharge. There is a lot of issue here. On 04/01/2025 at 12:49 PM, R3 when asked about her discharge plan. R3 said, I am hoping and praying to let me go home this week. I don't want to say anything to make it unfavorable for me. R3 stated that she currently on therapy (physical and occupational therapy). R3 said, I have no idea what the plan for my discharge. On 04/02/2025 at 10:15 AM, V4 (Social Worker) stated that facility use template to all residents on discharge care planning. And each resident's care plan will not show any difference. Notes will show difference in resident's situation but not care plan. R1, R2, R3, R4 and R5 care plan were reviewed with V4. V4 said, You cannot see anything difference there. V4 reviewed discharge summary and plan policy of the facility. After review V4, I see what you mean. I thought it was for the meeting of the IDT not the actual care plan. On 04/03/2025 at 12:25 PM V1 (Administrator) stated that she was not able to review care plan of residents that were reviewed. Moving forward, facility will identify care plan improvement to make it person-centered. Discharge Summary and Plan Policy dated 01/2024, reads: Policy statement, when a resident's discharge plan is anticipated, a discharge summary and post-discharge plan will be developed to assist the resident to adjust to his/her new living environment. Pre-discharge plan will be developed by the Care Planning/Interdisciplinary Team (IDT) with the assistance of the resident and his or her representative. Care Plans - Comprehensive Person-Centered policy dated 09/2023, reads: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet resident's physical, psychosocial and functional needs, that are identified through evaluation and assessment, is developed, and implemented for each resident. The comprehensive, person-centered care plan will include the resident's stated preference and potential for future discharge, including his or her desire to return to the community and any referrals made to local agencies or other entities to support such desire. It will also include discharge plans.

Based on interview and record review, the facility failed to provide adequate supervision and failed to follow the Care Plan implementing fall prevention interventions to one resident (R1) reviewed for resident injury. This failure resulted in R1 falling and sustaining bilateral subdural hemorrhages and a right parietal subarachnoid hemorrhage. R1 was admitted to the intensive care unit. Findings include: R1's hospital records, dated 2/14/2025, documents, in part, . presents to ED (emergency department) with chief complaint of Fall . Patient (R1) sustained hematoma to left orbit and skin tear to left elbow . CT (computed tomography) Cervical Spine WO (without) contrast, CT head WO Contrast, 2/14/2025 10:56 PM. Findings: Head: Small acute bilateral cerebral convexity subdural hematomas measuring 5 mm on the left and 3 mm on the right without significant mass effect. There is adjacent small right parietal subarachnoid hemorrhage measuring 7 mm. There is mild hyperdense thickening along the right tentorium compatible with small subdural hemorrhage . Drowsiness responding very minimally with pain stimulus. Patient admitted for subdural hematoma secondary to trauma more of conservative management at this time . Patient (R1) is a 92 y.o. (year old) male who presents to the ICU (intensive care unit) for bilateral subdural hematomas and small right subarachnoid hemorrhage . R1's progress note, dated 2/15/25 at 7:49 am, documents, in part, Called ER (emergency room ) at (hospital) ., resident admitted with DX (diagnosis): subdural hematoma, kitchen, pharmacy and housekeeping notified. R1's Fall Risk Assessment, dated 2/12/2025 at 10:10 am, documents, in part, a total score of 25 which indicated R1 is at a moderate risk for falls. R1's Care Plan, start date 11/19/24, documents, in part, (R1) is at risk for falls related to change in environment. (R1) wants to remain free from injury related to falls over the next review period . Keep bed at the appropriate height . R1's Care Plan, admitted date 2/20/25, documents, in part, (R1) needs assistance with daily ADL (activities of daily living) care . Bed Mobility: (R1) need extensive assistance with 2 person staff support. I (R1) use 2 side bed assistive device(s) . Toileting: I (R1) need total assistance with 2 person staff support. R1's Face Sheet documents medical diagnoses that include but are not limited to dementia, osteoarthritis, bilateral hearing loss, stiffness of right knee, stiffness of left knee, unsteadiness on feet, lack of coordination, need for assistance with personal care, muscle weakness, and difficulty in walking. R1's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview of Mental Status (BIMS) score of 01 which indicates that R1's cognition is severely impaired. R1 is unable to be interviewed due to R1's mental status. On 3/17/2025 at 12:33pm, V6 (R1's Family Member) said, I (V6) was notified of (R1's) fall on February 14th (2/14/25) by the facility. The CNA (V8 Certified Nursing Assistant) had the bed all the way up because she's (V8) tall. She (V8) went to the sink to go get a rag and that's when he (R1) fell . She (V8) shouldn't have left the bed up like that and shouldn't have left him (R1) at the edge of the bed. They (facility) called me at like 10:30 pm. I (V6) told them (facility) that I (V6) don't ever want her (V8) to touch him (R1) again. He (R1) has Alzheimer's. They (staff) should know better. Can you believe they (facility) didn't fire her (V8)? They (facility) just moved her (V8) to a different floor. He (R1) has been at this facility for 4 years. I (V6) have visited him (R1) every day since he's (R1) been here. Just recently I (V6) don't visit him on Saturdays because my family made me. On 3/17/25 at 1:40pm, V7 (Nurse Practitioner) said, Yes, I know (R1). I've been taking care of him (R1) since se he got here. Like for 3 to 4 years. I've been here 8 years. All I know is he fell off the bed. I didn't directly assess (R1). He came back with the bleed, non-operable. (R1's) dementia was advancing and he was having trouble swallowing. No, I just heard he was getting changed and fell somehow. I'm a subcontractor. Not directly employed by facility. When asked if the fall caused harm to R1, V7 replied, It didn't help him. In a way yeah. On 3/17/25 at 2:18pm, V8 (CNA) said, Yes, I was the CNA for him (R1) when he fell out of bed. It was around 9:50 pm on Valentine's Day. I was doing my last check and change. I put him on the potty, and he took a poo. I needed more material, so I went to the sink to get towels. When I turned around, I seen him falling and tried to catch him. He rolled over on me. The bed was still up to about my hip. I did not let it (R1's bed) back down. Normally everything be cool. Yes, I should have all supplies available when I do care. On 3/18/25 at 10:58 am, V3 (Interim Director of Nursing/DON) said, I know him (R1) a little bit. I am familiar with the incident itself (Fall that occurred on 2/14/25). I was notified of incident, (R1) sent out, report came in as a result of fall and an intracranial bleed. When interviewing the CNA (V8) it was a witnessed fall. (V8) went into room to provide care, stated (R1) had an unexpected bowel movement and she went to get additional supplies. In her words, (R1) was in bed, laying on right side, (V8) went to the sink and observed (R1) leaning further over. She (V8) tried to reach (R1) but was unsuccessful and (R1) fell from the bed to the floor. (R1) was assessed by the nurse and sent out. Residents on LAL (low air loss mattress) should have 2 person assist. Based off that, I began educating staff when residents are on a low air loss mattress, they (residents) should be a 2 person assist because when you're (residents) on air mattresses they (air mattresses) are constantly shifting. Moving forward LALs should be a 2 person assist for safety. She knew stepping away from the bedside was not a good call. As a one person assist, she should have repositioned him on his back, centered, and lowered the bed. Don't step away from the bed until lowered and positioned in bed. All those safety checks should have been done. If she would have done the safety checks the fall would likely not have happened. On 3/18/25 at 11:32am, V1 (Administrator/Executive Director) said, I am familiar with (R1). I (V1) am familiar with the incident of him falling out of the bed (fall incident on 2/14/25). When asked if R1's fall incident on 2/14/25 was it preventable, V1 replied, Possibly but I'm (V1) not a nurse. When asked if R1's fall incident on 2/14/25 caused harm to R1, V1 replied, I (V1) don't feel it changed his condition. He (R1) has been declining. I'm (V1) not a nurse to assess and clinically cannot make that statement. R1's FRI (facility reported incident), dated, 2/14/25, documents, in part, On 2/14/25 at approximately 9:50pm (R1) was receiving incontinence care from a CNA (certified nursing assistant, V8). The CNA rolled him on his right side and then stepped away to grab more wipes and soap to clean him. The CNA turned back towards and noticed he was leaning towards the edge of the bed. She quickly tried to get to the bed but (R1) rolled off the bed hitting his head on the floor . A bump on the right side of his forehead was found . 911 was called . He was transferred to the hospital . The RN (registered nurse) followed up with the hospital and he was admitted with subdural hematoma. Facility policy titled, Safety and Supervision of Residents, revised date 12/2017, documents, in part, . C. Residents should be visualized for safety during routine rounds and per care plan for individual needs . Facility presented document titled, Procedure: Assisting the Nurse in Examining and Assessing the Resident, revised date 12/2017, documents, in part, The purpose of this procedure is to assist the nurse in gathering information about the overall condition of the resident and his/her performance of activities of daily living (ADL). With a goal that the resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that a decline was unavoidable. A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming and personal hygiene . A. Activities of daily living (AOL) include the resident's physical, psychological, social, and spiritual activities. B. During daily contact with the resident, observe the resident's level of independence in performing ADL. While observing the resident, note if the resident performs activities of daily living: 1. Without assistance; 2. With some assistance; or 3. With total assistance; . E. Toileting -when assisting with personal toileting needs, note: 1. Assistance needed with going to the bathroom; . Facility policy titled, Fall Policy, revised date 7/2023, documents, in part, . 1. Fall Risk Assessment form (or similar fall risk evaluation) should be utilized to complete the evaluation of the residents' potential for falls during the admission process . Fall Risk Assessment form (or similar fall risk evaluation) should be completed quarterly, with significant change MDS Minimum Data Set) Assessment and after every fall .

Based on observations, interviews, and record reviews, the facility failed to a.) ensure all food items were labeled with an opened and use by date, b.) discard expired food based on use by date documented on label, c.) follow manufacturer guidelines for storage. These failures have the potential to affect all 132 residents receiving food prepared in the facility's kitchen. Findings include: On [DATE] at 9:12 AM, V11 (Dining Services Director/Certified Dietary Manager) stated all items are marked with a received by label which contain the date the item was delivered. V11 stated the kitchen uses a label machine to generate label stickers to put on all prepared or opened refrigerated items and opened non-refrigerated food items. The label stickers generated by the label machine has an area to write in the name of the product, the opened date (today's date) and the use by date or expiration date (Good Thru). V11 stated the use by or best by dates vary depending on what the product is. V11 stated the kitchen staff should be making sure all food items are labeled and that they are discarding any items past their use by, or expiration date based on the date written on the label stickers to keep the resident's safe. On [DATE] at 9:24 AM, observed in the Walk-In Refrigerator the following items: 1.) Two containers of prepared mashed potatoes with a label sticker documenting today's date [DATE] and good thru [DATE]. V11 stated the mashed potatoes were left over and should have been discarded on [DATE]. 2.) A small bowl of cooked oatmeal with a label sticker documenting product as grain and today's date [DATE] and good thru [DATE]. V11 stated the person who filled out the label using the label machine incorrectly labeled the item which is why the good thru date was wrong. V11 stated the good thru or used by date should have been [DATE] which means the items should have been thrown out [DATE]. On [DATE] at 9:35 AM, observed in [NAME] Prep Area/Spice Rack the following item: 1.) An opened two-quart container of Low Sodium Soy Sauce labeled with a label sticker documenting today's date [DATE] and good thru date [DATE]. Observed on the back of the product manufacturer printed on label Refrigerate After Opening. V11 stated the item should have been discarded on or before [DATE] based on the good thru date written on the label sticker. V11 stated to V12 (Chef Manager) it says on the label that it should be refrigerated after opening. V12 read the manufacturer label and said, yes, this should have been refrigerated. On [DATE] at 9:39 AM, observed in Dry Storage Room the following items: 1.) A large bin of panko breadcrumbs labeled with label sticker documenting today's date [DATE] and good thru [DATE].V11 observed the label and stated that needs to be switched out. It is expired based on the label. 2.) An opened 25-pound bag of pearled barley with no label on it. V11 stated the pearled barley should have a label on it with an opened and expiration date. 3.) A opened 25-pound bag of dried milk labeled with a label sticker documenting today's date [DATE] and good thru [DATE]. V11 stated the label expired so the item will be thrown out. Facility provided document titled, Resident Listing Report with report date [DATE] listing 132 residents with their diet orders. Facility provided document titled, Patients Who Are NPO undated with one resident's name listed. Facility provided policy titled Food and Supply Storage dated ,d+[DATE] which documents in part, 1.) All food, non-food items, and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and the wholesomeness of the food for human consumption. 2.) Cover, label and date unused portions and open packages. Complete all section on the orange labeling system. Products are food through the close of business on the date noted on the label. 3.) Discard food past the use by date or expiration date.

Based on observations, interviews, and record reviews, the facility failed to dispose eye drops after the discard date, refrigerate an unopened insulin pen, and lock a medication cart when not in use or in view for two out of four carts reviewed for medication storage and labeling. The facility also failed to properly dispose of R76's controlled medication after opening and failed to ensure controlled medications for R64 were under a double lock for 1 of 4 medication carts and 1 of 2 medication rooms reviewed for medication storage and labeling. Findings include: 1.) On 10/01/2024 at 2:14 PM, surveyor reviewed the medication cart designated for the intermediate and memory-impaired units with V6 (Registered Nurse). There was a bottle of Systane Gel Eye Drops for R44. The written open date was 8/28 and the written discard date was 9/28. V6 stated V6 did not notice the discard date that morning. V6 stated staff should have tossed the medication and V6 will reorder it. R44's Physician Orders document in part Systane Gel Eye Drops place one (1) drop into both eyes twice a day. 2.) In the same medication cart, there was an unopened Levemir (insulin) Flexpen 100 units for R19. The label on the packaging reads to refrigerate until use. V6 stated the Levemir Flexpen was unopened and should have been in the fridge. R19's Physician Orders document in part an order for Levemir Flexpen 100 unit/milliliter give 25 units subcutaneously every morning for Type 2 Diabetes Mellitus. 3.) On 10/02/2024 at 8:55 AM, surveyor observed V29 (Registered Nurse) prepare medications for R173. At 9:06 AM, V29 entered R173's room with the prepared medications and closed the bedroom door leaving the medication cart in the hallway unlocked and unsupervised. R173 took the medications at 9:08 AM. At 9:10 AM, V29 and surveyor exited the room. The medication cart remained unlocked. V29 stated there were medications for 11 residents on the cart. Facility's Storage of Medications policy (last approved 01/2024) documents in part: The community shall store all drugs and biologicals in a safe, secure, and orderly manner. The nursing associates shall be responsible for maintaining medication storage AND preparation areas in a clean, safe, and sanitary manner. The community shall not use discontinued, outdated, or deteriorated drugs or biologicals. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport suck items shall not be left unattended if open or otherwise potentially available to others. Medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses' station or other secured location. Facility's Discarding and Destroying Medications policy (last approved 01/2024) documents in part: Medications will be disposed of in accordance with federal, state and local regulations governing management of non-hazardous pharmaceuticals, hazardous waste and controlled substances. 4.) R76's Physician Orders documented in part an order for Tramadol Hydrochloride 50 MG (milligram) tablet take one tablet by mouth every six hours as needed for pain. According to the Drug Enforcement Administration - Diversion Control Division, Tramadol is a Schedule IV controlled substance. On 10/01/2024 at 2:37 PM, surveyor reviewed the controlled medications bin in the medication cart with V27 (Registered Nurse). R76's Tramadol 50 MG blister pack had nine pills. The ninth pill slot was torn and taped over. V27 stated V27 didn't know who did that or why they did it. V27 stated the nurse was supposed to discard the pill once it was opened. On 10/03/2024 at 8:28 AM, V3 (former Director of Nursing/Registered Nurse Supervisor) stated R76's Tramadol should have been disposed of after the nurse broke the seal. V3 stated the nurse should have disposed the controlled medication with another nurse as witness. 5.) On 10/01/2024 at 9:20 AM, V5 (Certified Nursing Assistant) entered the utility room to retrieve ice water. On 10/01/2024 at 3:14 PM, V28 (Agency Registered Nurse) let surveyor into the first-floor utility room. Other non-nurse staff such as V5 entered the utility room multiple times earlier in the day. Inside the room there was a locked refrigerator designated for medications. In the refrigerator there were two bags of controlled medications for R64. The first bag had 20 prefilled syringes of Lorazepam (antianxiety medication) and the second bag had 10 prefilled syringes of Lorazepam. These two bags were with the other medications (vaccinations and insulins) in the fridge and not in another designated locked area. R64's Physician Orders document in part that R64 was taking the medication for anxiety and nausea. According to the Drug Enforcement Administration - Diversion Control Division, Lorazepam is a Schedule IV controlled substance. On 10/01/2024 at 2:48 PM, V4 (Infection Preventionist) and V27 (Registered Nurse) stated controlled medications should be under double lock. On 10/03/2024 at 8:28 AM, V3 stated facility had to order lockboxes for the controlled medications in the fridge. V3 stated the controlled medications are now under double lock. Facility's Controlled Substances policy (last approved 06/2022) documents in part: The community shall comply with laws, regulations, and other requirements related to handling, storage, disposal, and documentation of schedule II-V and other controlled substances. Controlled substances must be stored in the locked medication room or medication cart in a locked container, separate from containers for any non-controlled medications. Unless otherwise instructed by the Director of Nursing Services, when a resident refuses a non-unit dose medication (or it is not given), or a resident receives partial tablets or single dose ampules (or it is not given), the medication shall be destroyed and may not be returned to the container.

Based on observations, interviews, and record reviews, the facility failed to a.) follow their policies by not wearing the appropriate Personal Protective Equipment (PPE) for residents on Enhanced Barrier Precautions (EBP) during high-contact resident care activities for 4 (R8, R28, R54, R223) residents and b.) handle and contain soiled linen during linen changing and transport. These failures have the potential to affect all residents residing on the first floor and second floor units. Findings Include: 1.) R28 has diagnosis not limited to Acute Embolism and Thrombosis of Femoral Vein, Bilateral, Localized Edema, Polyneuropathy, Unsteadiness on feet, Mature T/NK-Cell Lymphoma, Muscle Spasm, Thrombocytopenia and Heart failure. R28's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 15 indicating intact cognitive response. Physician Order dated 09/06/24 document in part: Enhanced Barrier Precaution due to wound. Care Plan Document in part: Place (EBP) Enhance Barrier Precaution signage and PPE (Personal Protective Equipment) supplies at entrance to resident room. R28 is incontinent of bladder. On 10/01/24 at 12:09 PM surveyor entered R28 room with signage posted on the door indicating Enhanced Barrier Precautions and observed bed linen, a blue pad, and a gown on the floor in front of the sink near the entrance door. R28 was observed sitting in a wheelchair at the bedside. The surveyor asked R28 who placed the linen on the floor. R28 responded, the certified nurse assistant left all of that junk on the floor since I got up about 10:30 AM. On 10/01/24 at 12:12 PM the surveyor asked R28 if it would be alright to press the call light. R28 agreed. At 12:13 PM V18 (Certified Nurse Assistant/CNA) entered R28 room. The surveyor asked V18 was there a reason the linen was on the floor. V18 responded, I was going to get back to it. I will take care of it now. V18 retrieved a pair of gloves from the glove box on the wall then exited R28's room. V18 returned to R28 with a linen hamper, put on the pair of gloves then began picking up the bed linen, blue pad and gown from the floor placing them in the linen hamper. V18 then exited the room with the hamper. The surveyor asked R28 did V18 wear a gown when she was providing his care. R28 responded, No, V18 did not wear a gown. On 10/01/24 at 12:15 PM V18 (CNA) stated I changed R28 bed and brief then had to put someone else on the toilet. I was going to come back to it. Surveyor asked V18 did she wear PPE (Personal Protective Equipment) when she (V18) provided R28's care. V18 responded, Yes, I wore gloves. I toileted and changed R28's brief. Surveyor made V18 aware of the Enhanced Barrier Precaution was posted on R28's door that indicates Everyone must: Clean their hands, including before entering and when leaving the room. Providers and staff must also: wear gloves and a gown for the following high-contact resident care activities. Dressing, Bathing/Showering, Transferring, Changing Linens, Providing Hygiene, changing briefs or assisting with toileting, Device care or use: intravenous line, urinary catheter, ostomy, feeding tube, & tracheostomy. Wound Care: any skin opening requiring a dressing. V18 stated I should have worn a gown. On 10/02/24 at 10:56 AM V4 (Infection Preventionist) stated when a resident is on EBP (Enhanced Barrier Precautions) the type of PPE (Personal Protective Equipment) that should be worn are gloves and a gown for any high contact. Including: Any time you are close to someone with an indwelling medical device that sticks on the outside of the body and goes inside the body. PICC (Peripherally Inserted Central Catheter) lines and Midlines but peripheral IV (intravenous) are not. During patient care, transferring, helping cleanup, bathroom, showering, linen change, during wound care, gastric tube and manipulating the indwelling medical device you need to wear a gown and gloves. It depends if there is an MDRO or not they are more susceptible, and we are to protect the resident. If a resident has an MDRO Enhanced Barrier Precautions is more to prevent the spread of MDRO's in nursing homes. If the linen is to be removed and if it was unexpected, we have extra clear bags. The linen should not have been put on the floor because if there is an infection it is on the floor. That is just a standard of nursing care. She should have worn gloves and gown when caring for the resident on Enhanced Barrier Precautions and not just gloves. When doing wound care, a gown and gloves should be worn. On 10/04/24 V1 (Administrator) emailed an (EBP) Enhance Barrier Precaution In-service with a list of staff names and signatures but no specific topics that were covered. Policy: Titled Enhanced Barrier Precautions Last Revised 03/24 document in part: EBP (Enhanced Barrier Precautions) in addition to Standard and Contact Precautions, shall be implemented during high-contact resident care activities when caring for residents that have an increased risk for acquiring and/or transmitting a multidrug-resistant organism (MDRO) such as a resident with wounds, indwelling medical devices and residents with colonization with an MDRO. Purpose: to prevent opportunities for the transfer of MDRO's to associate's hands and clothing during care. 1. Enhanced Barrier precautions (EBP) are an infection control intervention designed to reduce transmission if resistant organisms that employs targeted gown and gloves use during high contact resident care activities when contact precautions do not otherwise apply. 2. EBP are indicated (when Contact Precautions do not otherwise apply) for residents with any of the following: Wounds or indwelling medical devices, regardless of MDRO colonization status. 4. Enhanced Barrier Precautions expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDRO's to staff hands and clothing. 5. Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions Include: 1. Dressing. 2. Bathing/showering. 3. Transferring. 4. Providing Hygiene. 5. Changing linens. 6. Changing briefs or assisting with toileting. 8. Wound care. Titled Environmental Services - Laundry and Linen last approved 01/24 document in part: The purpose of this policy is to provide a process for the safe and aseptic handling, washing and storage of linen. Standard Precautions: C. Consider all soiled linen to be potentially infectious and handle with standard precautions. Transmission - Based Precautions: A> If a resident is placed in Transmission-Based Precautions linen will be handled, stored, and transported to prevent the spread of infection, by use of appropriate personal protective equipment. Bagging and Handling Soiled Linen: A. Soiled linen should be placed directly into a covered laundry hamper which can contain the moisture. C. Place any linen saturated with blood or body fluids into a leak-resistant bag before placing it into the hamper. Titled Infection Prevention and Control Program review 04/24 document in part: 4. The (IPCP) Infection Prevention and Control Program is designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Titled Standard Precautions last approved 01/24 document in part: B. Standard Precautions shall apply to the care of all residents in all situations regardless of suspected or confirmed presence of infectious diseases. B. Gloves 2. Gloves are worn when in direct contact with a resident who is infected or colonized with organisms that are transmitted by direct contact. D. Gowns 1. Wear a gown (clean, non-sterile) to protect skin and prevent soiling of clothing during procedures and resident care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, or excretions or causing soiling of clothing. G. Linen: 1. Linen soiled with blood, body fluids, secretions, excretions are handled and processed in a manner that prevents skin and mucous membrane exposures, contamination of clothing, and avoids transfer of microorganisms to other residents and environment. Titled Transmission Based Precautions reviewed 04/24 document in part: Standard Precautions: Standard Precautions include hand hygiene, environmental cleaning and disinfection, risk assessment with use of appropriate personal protective equipment (PPE) based on activities being performed, injection and medication safety, and proper handling of sharps and linens. 1. Gloves - worn when contact with blood, or other potentially infectious materials, mucous membranes, in-intact skin, potentially contaminated skin, or contaminated equipment could occur. 2. Gowns - worn during procedures and resident care activities when HCP (Health Care Provider) uniform or clothing may contact blood/body fluids, secretions, and excretions. 7. Proper Handling of Linens - Handled in a manner that prevents transfer of microorganisms to others and to the environment; soiled linen is contained. 40061 2.) R223 is a resident of the facility. R223's Face Sheet and Physician Orders document in part a medical diagnosis of cellulitis of the left lower limb. R223's Physician Orders document in part an order for Enhanced Barrier Precautions due to [urinary] catheter and wounds (start date 9/25/2024). R223's Care Plan documents in part that R223 is at risk for acquiring or transmitting infection due to the indwelling urinary catheter and wound to the left foot (onset 9/24/2024). Approaches include to Follow established infection prevention protocol including Enhanced Barrier Precautions and Staff to wear gowns and gloves for high contact resident care. On 10/01/2024 at 12:09 PM, there was an Enhanced Barrier Precautions (EBP) sign posted on R223's door. It documented in part to wear gown and gloves when changing linen and providing hygiene. At 12:10 PM, V23 (Agency Nurse) and V24 (Contracted CNA) were in the room with R223. V23 and V24 did not don gowns. At 12:13 PM, V24 left R223's room to get an incontinence pad. V24 stated they were changing R223. V23 was in the room emptying a urinal into the bathroom. V23 wore gloves but did not have a gown on. At 12:14 PM, V24 returned to R223's room. V24 grabbed gloves from the PPE (Personal Protective Equipment) bin outside of R223's room but did not don a gown. At 12:21 PM, V23 exited R223's room carrying a soiled incontinence pad with gloved hand. It was not contained in a bag. V23 carried the soiled incontinence pad down the hall and deposited it in a soiled linen hamper outside of R31's room. At 12:25 PM, V24 did not know why R223 was on EBP. V24 stated R223 was on basic precautions. V24 stated V23 and [V24] did not wear a gown during R223's care. 44103 3.) On 10/1/24 at 11:14 AM, R8 was lying in bed and noted an Enhanced Barrier Precautions signage posted on R8's door. V5 (CNA) was interviewed and stated V5 was assigned to R8 and was about to dress and get R8 up. V5 stated V5 helps answering call lights for all first-floor residents and helps cover other residents when other CNAs go on break. At 11:21 AM, Surveyor observed V5 provided incontinence care to R8 without proper PPE. V5 wore gloves but did not wear the isolation gown. R8's clinical records show a physician order of Enhanced Barrier Precautions (start date 7/1/24). R8's care plan shows R8 is on Enhanced Barrier Precautions due to colonization with Multidrug-Resistant Organism (MDRO), Vancomycin-Resistant Enterococci (VRE) in urine. 4.) On 10/2/24 at 9:24 AM, R54 was lying in bed and an Enhanced Barrier Precautions signage posted on R54's door. At approximately 9:32 AM, Surveyor observed V3 (Former Director of Nursing/Registered Nurse Supervisor) performed wound treatment for R54 without wearing proper PPE. V3 wore gloves but did not wear the isolation gown. V3 stated R54 has stage 2 sacral pressure ulcer with daily wound treatment. V3 stated she is helping the facility today with troubleshooting dealing with families and other issues that will arise. R54's clinical records show a physician order of Enhanced Barrier Precautions (start date 7/26/24). R54's care plan shows R54 is on Enhanced Barrier Precautions due to wound.

Based on observation, interview, and record reviews the facility failed to make reasonable accommodations for two (R1, R2) of four residents. This failure resulted in R1 sustaining a facility acquired pressure ulcer to left heel. Findings include: 1.) R1's clinical record documents in part, R1 is a [AGE] year-old admitted to the facility on [DATE], with the medical diagnosis of but not limited periprosthetic fracture, status post open reduction and internal fixation to right hip from fall at home, right hip pain, atrial fibrilla, heart disease, convulsions, and anxiety disorder. R1's minimum data set (MDS) Brief Interview Mental Status Score (13), indicates R1 is cognitively intact. R1's clinical notes documents in part: Nursing note 7/22/23 at 5:57 PM Received R1 from hospital, alert and oriented x3. R1 states, the beds is too small, and my room is dirty. R1 expressed concerns to V9 (R1's Former Facility Physician). Writer spoke with V9 regarding R1 concerns and is actively looking for another bed. Wound Assessment Report date 8/10/23- wound type: Pressure Ulcer, acquired. Left heel unstageable due to suspected deep tissue injury (DTI). Measurements 2.80cm x 2.40cm (centimeters). On 11/11/23 at 8:00 AM, V10 (R1's Family Member) stated, R1 developed a sore on his left heel due to his heel being pressed against the foot board for three months. V11 (Agency Registered Nurse) was made aware the day R1 was admitted to the facility, the bed was too small, not long enough. I also expressed my concern that R1's bed was not long enough to V2 (Executive Director), V3 (Director of Nursing), and nothing was done about it. On 11/11/23 at 2:08 PM, V5 (Wound Care Nurse) stated, R1 acquired a left heel wound on 8/10/23. The left heel was a fluid filled blister dark in color. A DTI is caused by pressure. If a resident foot is pressed against the foot board, it could potentially cause a pressure ulcer injury. 2.) R2's clinical record documents in part, R2 is an [AGE] year-old admitted to the facility on [DATE], with the medical diagnosis of pneumonia, acute respiratory failure, Parkinson's Disease, dementia, acute kidney disease, and essential hypertension. On 11/11/23 at 10:26 AM, surveyor and V8 (Registered Nurse) observed R2 resting in a low air loss mattress bed. R2's knees were bent, and his feet was pressed against the foot board. On 11/11/23 at 10:28 AM, Asked R2 if he was comfortable, R2 said No. Asked R2 did his feet hurt, R2 said Yes. V8 and nursing staff manually lifted and slid R2 up off the foot board to the very top of the bed. V8 removed R2's socks, observed R2's bilateral heels were reddened, and tender to touch. On 11/11/23 at 10:40 AM, V8 stated, R2 has been here in the facility for a long time. R2 is alert and oriented x 1-2, able to answer basic questions related to the present. R2's memory is not good but is aware of the present. R2 is currently on an air mattress because he wishes to stay in bed most of the time as a preventative measure. R2 does not have any pressure ulcers. I will rub skin cream on his feet and see if the redness goes away. On 11/11/23 at 2:40 PM, V3 (Director of Nursing) stated, I was not made aware that R1's bed was too short. R1 or R1's family did not make me aware the bed length needed adjusting. R2 does not have any pressure ulcer, but his Braden score indicates R2 is at high risk for a pressure ulcer. If a resident's feet is pushed or pressed against the foot board, it could potentially cause a pressure ulcer. Any at risk residents should have their feet off loaded, to prevent pressure injuries. On 11/11/23 at 11:31 AM, V6 (Plant Operations Director) stated, I remember R1. I did not receive any concerns regarding his bed being too short. I could have accommodated R1, but I did not know. I could have placed a bed extender on R1 bed to give him 4 more inches in length. Today I been here for two hours, I was not made aware that R2's bed needed to be extended. R2 has an air loss mattress which is 80 inches in length. I will go now and place an extender on R2's bed which will extend the bed four more inches. On 11/12/23 at 2:42 PM, V2 (Executive Director) stated, I was not made aware that R1 complained to the nurse on 7/22/23, of his bed being too small as documented in R1's nursing notes. R1's concerns should have been taking care of immediately and documented on a concern form. I will in-service all staff regarding resident's concerns. The facility should make reasonable accommodations to meet the resident's needs. Policy: Document in part -Federal Nursing Home Resident Rights: -A facility environment must treat each resident with respect and dignity and care for each resident in a manner and in an that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality and preferences.

Based on observation, interviews, and record reviews the facility failed to follow their wound prevention policy for two residents (R1, R2). The facility failed to ensure one (R1) did not develop a pressure wound. The facility also failed to ensure R2 did not develop bilateral reddened heels despite being on a low air loss mattress. This failure resulted in R1 developing a deep tissue pressure injury to his left heel. Findings include: 1.) R1's clinical record documents in part, R1 is a [AGE] year-old admitted to the facility on [DATE], with the medical diagnosis of but not limited periprosthetic fracture, status post open reduction and internal fixation to right hip from fall at home, right hip pain, atrial fibrilla, heart disease, convulsions, and anxiety disorder. R1's minimum data set (MDS) Brief Interview Mental Status Score (13), indicates R1 is cognitively intact. R1's (7/22/23) clinical notes documents in part: 7/22/23 at 5:57 PM Nursing note: Received R1 from hospital, alert and oriented x3. R1 states, the beds is too small, and my room is dirty. R1 expressed concerns to V9 (R1's Former Facility Physician). Writer spoke with V9 regarding R1 concerns and is actively looking for another bed. Wound Assessment Report date 8/10/23 wound type: Pressure Ulcer, acquired. Left heel unstageable due to suspected deep tissue injury (DTI). Measurements 2.80cm x 2.40cm (centimeters). On 11/11/23 at 8:00 AM, V10 (R1's Family Member) stated, R1 developed a sore on his left heel due to his heel being pressed against the foot board for three months. V11 (Agency Registered Nurse) was made aware the day R1 was admitted to the facility, the bed was too small, not long enough. I also express my concern that R1's bed was not long enough to V2 (Executive Director), V3(Director of Nursing), and nothing was done about it. 2.) R2's clinical record documents in part, R2 is an [AGE] year-old admitted to the facility on [DATE], with the medical diagnosis of pneumonia, acute respiratory failure, Parkinson's Disease, dementia, acute kidney disease, and essential hypertension. On 11/11/23 at 10:26 AM, surveyor and V8 (Registered Nurse) observed R2 resting in a low air loss mattress bed with his head elevated. R2's knees were bent, and his feet was pressed against the foot board. On 11/11/23 at 10:28 AM, Asked R2 if he was comfortable. R2 said No. Asked R2 did his feet hurt, R2 said Yes. V8 and nursing staff manually lifted and slid R2 up off the foot board to the very top of the bed. V8 removed R2's socks, observed R2's bilateral heels were reddened, and tender to touch. On 11/11/23 at 10:40 AM, V8 stated, R2 has been here in the facility for a long time. R2 is alert and oriented x 1-2, able to answer basic questions related to the present. R2's memory is not good but is aware of the present. R2 is currently on an air mattress because he wishes to stay in bed most of the time as a preventative measure. R2 does not have any pressure ulcers. I will rub skin cream on his feet and see if the redness goes away. On 11/11/23 at 2:08 PM, V5 (Wound Care Nurse) stated, R1 acquired a left heel wound on 8/10/23. The left heel was a fluid filled blister dark in color. A DTI is caused by pressure. On 8/10/23 R1's left heel DTI measured 2.8cm x 2.4cm, 8/18/23 measured the same, 8/25/23 left heel measured 2.7cm x 2.2cm, 9/1/23 left heel measured the same, on 9/13/23 left heel measured 2.7cm x 2.0cm, and on 9/16/23 R1 discharged home. If R2's heels were pressed against the foot board and his heels were red, it could potentially be a stage one pressure ulcer. I will assess R1's feet. If a resident foot is pressed against the foot board, it could potentially cause a pressure ulcer injury. Some high-risk factors are poor nutrition, immobility, incontinence, vary of diseases, and circulation problems. Some preventative measures are pressure reducing mattress, repositioning, nutritional support, and offloading pressure points. On 11/11/23 at 2:40 PM, V3 (Director of Nursing) stated, I was not made aware that R1's bed was too short. R1 or R1's family did not make me aware the bed length needed adjusting. R2 does not have any pressure ulcers, but his Braden score indicates R2 is at high risk for a pressure ulcer. If a resident's feet is pushed or pressed against the foot board, it could potentially cause a pressure ulcer. Any at risk residents should have their feet off loaded, to prevent pressure injuries. On 11/12/23 at 2:42 PM, V2 (Executive Director) stated, I was not made aware that R1 complained to the nurse on 7/22/23, of his bed being too small as documented in R1's nursing notes. R1's concerns should have been taking care of immediately and documented on a concern form. I will in-service all staff regarding resident's concerns. The facility should make reasonable accommodations to meet the resident's needs. Policy documents in part: Prevention of Pressure Injuries Protocol dated -1/2018 -Interventions and Preventive Measures -Place resident at risk of developing pressure injuries are placed on the pressure reducing surface. -Routinely assess and document the condition of the resident's skin. The care process should include efforts to stabilize, reduce or remove underlying risk factors. -Because a resident at risk can develop a pressure injury within 1-4 hours of the onset of pressure, the at-risk resident needs to be identified and have interventions implemented promptly to attempt to prevent pressure ulcers. -Consider off-loading pressure hourly if the head of bed is greater than 30 degrees. Pressure Injury Assessment/Treatment dated 1/2018 -Stage one-skin remains intact at this stage. Intact skin with a localized area of non-blanchable erythema, which may appear differently in dark pigmented skin.

Based on interviews and record reviews, the facility failed to obtain medications and insulin from the facility's emergency dispensary machine and failed to administer medications as prescribed for 2 (R1, R2) of 4 newly admitted residents reviewed for improper nursing care. This failure resulted in R1 not receiving ordered pain medication on admission and experiencing pain level of 10 on a pain scale of 0 to 10. Findings include: R1's diagnosis include but are not limited to Diabetes, Disease of the Spinal Cord and Low back Pain. 1. On 4/22/23 at 8:40 AM, R1 stated, I was admitted on ,d+[DATE] at 6PM. I was discharged on [DATE] back home with my husband. I had major surgery on my spine, needed therapy at the rehab center. Upon my admission, I did not receive my pain medication [hydrocodone], diabetes insulin medication, or heart medications until the next day. Throughout my stay, I did not receive my heart medication or pain meds daily as well. On 5/2/23 at 9:11 AM, R1 stated, I was in the hospital for spine surgery. I went to the facility for rehab services. When I arrived at the facility, I was in a lot of pain due to the bumpy ride from the hospital. The nurse told me that my pain mediation was unavailable. I explained to the nurse that my pain was a ten on a pain scale 0-10. My pain was so bad that I felt out of my mind. R1's medication administration record documents R1 received pain medication on 1/14/23 at 1:30 am, 9 days after admission. R1's medical record documents in part, face sheet: admitted on [DATE] at 6:41 PM. Physician orders: -Lantus 100 unit/ml inject 32 units into skin SQ (subcutaneous) daily at bedtime, order date 1/5/23, start date 1/5/23, end date 1/7/23. Electronic Medication Administration Record (EMAR) documents medication was not given on 1/5/23. -Levemir 100 unit/ml vial inject 32 units into skin SQ daily at bedtime, order date 1/5/23, start date 1/7/23. EMAR documents medication was not given on 1/7/23, and 1/9/23. -Atorvastatin 20mg take by mouth daily at bedtime, order date 1/5/23, start date 1/5/23.EMAR documents medication was not given on 1/5/23, 1/7/23, 1/9/23, and 1/15/23. -Norvasc (Amlodipine) 5mg by mouth daily, order date 1/5/23, start date 1/5/23. EMAR documents medication was not given on 1/7/23, 1/8/23, 1/11/23, and 1/17/23. -Lisinopril 40mg take one tablet by mouth daily, order date 1/5/23, start date 1/5/23. EMAR documents medication was not given on 1/7/23, 1/8/23, 1/11/23, and 1/17/23. -Norco (Hydrocodone) 7.5mg/325mg [milligrams] take one tablet by mouth twice a day at 6AM, and 2PM scheduled with no stop date, order date 1/13/23. EMAR documents medication was not given on 1/14/23 at 6AM, 1/17/23 at 6AM, 1/19/23 at 2PM, 1/23/23 at 2PM. -Norco (Hydrocodone) 7.5mg/325mg [milligrams] take one tablet every four hours as needed for pain, order date 1/5/23. EMAR R1 received documents the medication on 1/14/23 at 1:30 am. R1 Progress notes dated 1/5/23 through 1/25/23, no nursing documentation that medication was not given. Minimum data set-brief mental interview documents score is 15, indicates R1 is cognitively intact. Care plan dated 1/5/23 R1 has the following: potential for alteration in blood pressure; give medication as ordered, potential for hypo/hyperglycemia related to diabetes; medication as ordered and monitor blood glucose levels, impaired mobility related to cervical radiculopathy, myelopathy, status post cervical spinal surgery-chronic back pain; offer/provide pain medications. On 4/22/23 at 3:14 PM, V2 (Director of Nursing) stated, Newly admitted residents to the facility after 3:00PM, sometimes their medications may not have been delivered from pharmacy by the due time. My expectation for the nurses, if the medications are scheduled while the resident is in the building, they should receive their medications. By accessing the emergency medication machine or the emergency insulin box. If the needed medication is not available in the emergency medication machine, the nurse should call and notify the pharmacy, and the physician to see if there is a substitute available or received a new order. The new orders and the reason why the medication was not given should be documented in the resident's progress notes. According to R1's face sheet, R1 was admitted to this facility on 1/5/23 at 6:41 PM. R1's EMAR for January 2023 the following medications: Dated 1/5/23- atorvastatin 20mg, to take by mouth at bedtime (8PM) V8 (Registered Nurse) documented N which means the medication was not given, and 1/5/23, -Lantus 100unit/ml, inject 32 units subcutaneous at bedtime, V8 documented N which means the insulin was not given. I am not sure why V8 did not administer R1 medication or insulin. On 1/6/23, I went in to meet with R1, and introduced myself, R1 did not express any concerns regarding not receiving her evening insulin or medication on 1/5/23. 2. On 4/22/23 at 10:41 AM, R2 stated, I cannot remember when a was admitted , if I received all my medications. My admission process went smoothly, I arrived at the facility around 6PM. R2's medical record documents in part: face sheet, admitted on [DATE] at 7:39 PM. Physician orders: -Levemir 100 unit/ml vial inject 28 units into skin SQ daily at bedtime, order date 2/16/23, start date 2/17/23. Hospital medication form dated 2/16/23, documents to give Levemir on 2/16/23 at 9PM, EMAR documents medication was not given on 2/16/23. -Morphine (MS Contin) 12hour tablet 30mg every 12 hours scheduled (9AM, 9PM), documented on Hospital medication form dated 2/16/23, EMAR documents medication was not given on 2/16/23 at 9PM, 2/18/23 at 9AM, and 2/22/23 at 9PM. -Gabapentin 300mg capsule one cap by mouth at bedtime order date 2/16/23, start date 2/17/23, Hospital medication form dated 2/16/23, documents to give Gabapentin on 2/16/23 at 8:00 PM, EMAR documents medication was not given on 2/16/23. R2 Progress notes dated 2/16/23 through 2/28/23, no nursing documentation that medication was not given. Minimum data set-brief mental interview documents score is 15, indicates R2 is cognitively intact. Care plan dated 2/16/23, R2 has the following: Alteration in cardiovascular related to atrial fibrillation; give medications as ordered. Potential for alteration in blood pressure related to diagnosis of hypertension; give medications as ordered. Potential for hypo/hyperglycemia related to diabetes; give medications as ordered, monitor blood glucose as ordered. Alteration in comfort related to right hip pain, adenocarcinoma of lungs, rheumatoid arthritis; administer pain medication as ordered. 3. On 4/22/23 at 11:06 AM the surveyor, V3 (Agency Registered Nurse) and V4 (Registered Nurse) entered a locked clean utility room. V4 accessed the emergency medication machine and retrieved R4's hydrocodone 5/325mg (1-tablet) using a code from pharmacy. On 4/22/23 at 11:10 AM V4 stated, I been working here for [AGE] years. If a diabetic resident does not have their insulin available, I would call pharmacy for the insulin to be placed on the next delivery. However, if the resident blood glucose is high, I would borrow from another resident to save their life. The facility does not have any house stock or emergency stock of insulin available to use. In the medication med room, we have apple juice, orange juice and milk available to give to the residents that blood glucose level is slightly low. On 4/22/23 at 12:30 PM, V5 (Registered nurse) stated, There is always medication available, for heart medication, pain, or insulin. The heart medications and pain meds are stored in the facility's emergency medication machine. The insulin is stored on the first-floor medication room locked refrigerator. Surveyor and V5 entered the first-floor medication room. In the locked refrigerator, observed a clear locked container with Lantus, NovoLog, Levemir, Humalog, Novolin -R, Novolin -N, Novolin 70/30 insulins available. On 4/23/23 at 12:08 AM, V8 (Registered Nurse) stated, I work the night shift. I signed out R1's dated 1/5/23- atorvastatin 20mg, to take by mouth at bedtime and documented N which means the medication was not given, and 1/5/23, -Lantus 100unit/ml, inject 32 units subcutaneous at bedtime and I documented N which means the medication was not given. I only signed out the medication, because there was an agency nurse working and completed a paper documentation that V2 (Director of Nursing) keeps record of the papers. The paper EMARs V2 has, it will show that those medications were not given by the agency nurse. The agency nurse had to tell me that the medication was not administered in order for me to document that on the EMAR. The facility has an emergency medication machine and available emergency insulin. However, it was not my medication to give on the shift ahead of mine. 4/23/23 at 11:04 AM, V2 (Director of Nursing) stated, I found the paper medication administration record (MAR) for R1 that shows on 1/7/23 R1 did receive Levemir insulin from an agency nurse. The description column does document Lantus 100unit/ml to give 32 units at bedtime. However, Levemir and Lantus insulin are the same. The agency nurse was unable to discontinue the Lantus insulin order and write a new order for the Levemir insulin. R1's original MARs for January 2023, documents R1 did not receive Lantus insulin 100 unit/ml dose to give 32 units at bedtime (order start dated 1/5/23, end date 1/7/23), on 1/5/23, and 1/7/23. Agency staff is not in the system to complete admission documentation for a new resident. Only the staff nurses can complete new or re-admissions orders. There were multiple staff nurses completing R1, and R2's admission documentation including placing in physician orders. There was miscommunication between the staff nurses that completed the admissions and the agency nurses who was overseeing R1 and R2's care. Therefore, the agency nurses did not know to give certain medications that was due on those evenings. A newly admitted resident with a diagnosis of diabetes, staff should take and record the residents blood glucose level and administer insulin if not, it could potentially cause the resident blood glucose levels to be low or high above the normal limits. If a resident does not receive prescribed medications, it could potentially cause adverse symptoms to the resident, such as increase in blood pressure, or pain. On 4/22/23 at 10:00 AM requested full list of the emergency medication machine inventory list from V2. Received pages 20, 21, and 22 dated 6/21/2019. On 4/23/23 at 9:00 AM requested a full list of the emergency medication machine inventory list from V2. Received pages 8-14 dated 4/13/23. Surveyor did not receive the completed inventory list. Policies Reviewed: Documents in part Documentation of Medication Administration dated 1/22: Nurses shall document the medications administered to each resident on the resident's medication administration record. Follow physician orders as prescribed. Nursing Care of the Resident with Diabetes: Monitor and record blood glucose levels as prescribed and document the level. The physician will order the frequency of glucose monitoring. The management of individuals with diabetes should follow relevant protocols and guidelines.

Based on interview and record review, the facility failed to provide adequate supervision to R1. This failure resulted in R1 sustaining a fall which required R1 to go to the hospital due to sustaining a laceration with bleeding to the back of the head, requiring 5 staples. Finding includes: According to a face sheet, R1's diagnoses include Contracture, Rhabdomyolysis, Pressure Ulcer, Open Wounds, Neuromuscular Dysfunction of bladder, Dementia, Severe protein malnutrition and Acute kidney failure. R1's Minimum Date Set assignment dated 9/15/21, indicated R1 has a Brief Interview for Mental Status (BIMS) score of 8, which indicates resident has moderate impairment. Facility's Final Report of R1's Incident (2/4/22) documents in part: On January 31, 2022, at about 4:45 am the resident was found lying on the left side of the bed after CNA (Certified Nurse Assistant) heard a thud. The resident was alert and oriented to self-unable to relate what happened, VS BP 92/50, PR 70 RR 18 T 97.6 in no apparent distress and able to move limbs, verbalized pain to back of R1's head where bleeding was noted. Ice pack applied, and pressure to site. Neuro check performed and WNL (Within Normal Limits). Sent to emergency room via EMS (Emergency Medical Services) for further management. Investigation: On the day of the event, an agency CNA was providing incontinence care to R1 and turned R1 to R1's left side, in bed with a pillow on the side for support. He noted the soiled dressing to R1's coccyx and decided to call the nurse ' s attention so it can be changed. He verbalized first walking to the door and then walking to the nurse ' s station a few steps away to find the nurse when he heard a thud. He found R1 on the floor at the left side of R1's bed. Nurse and supervisor notified and provided assistance. R1 was not able to relate what happened and blood was noted on the floor from the back of R1's head. Ice pack and pressure applied to site and 911 called. Physician, POA (Power of Attorney) and hospice also notified. Resident was sent to the ED and 2 cm scalp laceration was repaired with 5 staples. CT scan of the head and spine was performed with negative results. R1 returned to the facility at 6:10 pm via superior ambulance resuming hospice care. On 3/7/22 at 9:48 am V2 (Director of Nursing) said she is new to the facility. V2 said, V3 (Certified Nursing Assistant) was assigned to R1 and is an agency employee. V2 said, on 1/31/22 V3 (CNA) was changing R1, he was doing incontinence care. R1 had a bowel movement and there was stool over R1's dressing (R1 had a wound). V2 said, V3 went to get the nurse, V4 (Registered Nurse/RN) to tell her the dressing was soiled and needed to be changed. V2 said, when V3 and V4 returned to the room, R1 was found on the floor. V2 said, facility does not have side rails or bed rails for their residents. V2 said, floor mats were intervention that was added after R1 fell . V2 said, R1 was laying on R1's back towards the left side on the low air loss mattress and R1 was not in the center of the bed. V2 said, it was not appropriate to leave a resident on a low air loss mattress like this because the mattress deflates on one side. V2 said, the bed should be left in low position and V3 (CNA) should have made sure the resident was in a safe space before he left the resident alone. V2 said, the call light was with the resident and V3 should have turned the call light on for the nurse to come to the room instead of leaving the resident. V2 said, facility has been trying to get in touch with V3, but he has not been answering his phone. The facility only got a statement from V3 the day of the incident. V2 said, all she knows is that the bed was not in the lowest position when R1 was found, and she does not know how high the bed actually was and R1 was left by V3 turned to the left side and not in the center of the low air loss mattress. On 3/7/22 at 10:37 am V4 (RN) said, that morning, V3 called her attention right before she was about to do her morning medication pass, that he needed help with R1 regarding the dressing on R1's back, it had to be changed because it was soaked. V3 informed V4 he was changing the resident's brief and noticed R1's dressing was soiled. V4 said, V3 ran out of the R1's room to tell V4 about the dressing and V4 asked why you left the resident unattended however V3 insisted she will go and change R1. V4 said, they heard a sound in R1's room and both ran to R1 and found R1 was on the floor. V4 said, she was so mad she told V3 see what did you do, you left the patient alone and (R1) fell . V4 said, V3 was sorry for what happened. R1 was lying on the floor, the bed was regular height, it was at working level and not all the way to the floor. V4 said, before V3 left R1's room, he did not put the bed to the floor and anyway the dressing could have been changed later. V4 said, R1's head was bleeding, she assessed the resident, did vital signs and called 911 because R1 needed to be send to the hospital. V4 said, V3 did wrong, he left the R1 unattended, and the bed was not in the lowest position. V4 said, according to V3, R1 was left on the edge of the bed, on the left side when V3 left the room. V3 said, V4 barely answered any questions to what happened. R1 was on a low air loss mattress, and the resident should be centered and not left on the edge of the bed, otherwise the bed is not balanced. V4 called R1's doctor to inform him the resident was found on the floor and was bleeding. V4 said, V3 left R1 unattended, without safety in place, R1 should not be left turned on the side, not in the middle of the bed and the bed should have been in the lowest position. On 3/7/22 at 10:53 am V2 said, R1 came back with staples 5 to the back of the head. The resident should have been left in the middle of the mattress. V2 said, residents on a low air loss mattress, can be tilted to the side, wedge can be used but the residents body needs to be in the middle of the bed. Because of the way the mattress works, it deflates when there is pressure applied to it, and residents body keep moving and resident can fall out of the bed if the resident is too close to the edge of the bed. On 3/7/22 at 11:03 am V3 (CNA) said, he was doing rounds, was providing incontinence care to R1 and noticed R1's soiled, he worked the night shift, and it was busy. V3 said, before he left R1's room to find V4, he lowered the bed but not all the way down. V3 said, he came out of the room and was calling for V4 to change the dressing. V3 said, before he knew the resident fell out of the bed and he came in with the nurse and found R1. V3 said, he believes he left R1 in the middle of the bed. V3 said, he did not press the call light to get V4's attention, and that was a mistake. V3 said, R1 was left alone for no more than 60 seconds. On 3/8/22 at 4:37 pm, V5 (R1's Physician) stated on 1/31/22 facility called him to make him aware there was an incident involving a CNA (Certified nursing Assistant) and R1. V5 said, he does not know the entire circumstance with the incident but does know that R1 slid off the bed. V5 said, the height of the bed was not an issue to V5, but R1 was left unattended and R1 had a poor postural balance. Meaning if R1 was left on R1's side, and R1 started to roll over, R1 would not be able to stop from falling. V5 said, the height of the bed would make a difference to what kind of injuries the resident would have when falling. V5 further said, low air loss mattresses are slippery and if a resident is left on their side and not in the middle of the bed they can slip from the bed. R1's (1/31/22) progress note by V4 (RN) documents in part: Resident head on the floor, noted with bleeding at the back of R1's head. R1's (9/21/21) Care Plan documents in part: Resident is at risk for falls due to generalized weakness secondary to rhabdomyolysis, wound infection, malnutrition, history of falls- Place bed in lowest position safe for resident and wheels locked. R1's (1/25/22) Care Plan documents in part: Resident needs assistance with ADLS due to impaired mobility and weakness. R1's (9/9/21) Physician Orders document in part: Fall Precaution. Facility's Falls Prevention program documents in part: c. the documentation of the identified interventions should be maintained in the resident clinical record and available to the direct care associates. Facility's certified nurse assistant job description, documents in part: Assures resident safety by identifying safety hazards.