Every finding on record at Avir at Bradburn

Based on observation, interview and record review the facility failed to ensure the resident assessment accurately reflected the resident's status for 3 of 16 residents (Residents #6, #27 and #29) reviewed for accuracy of assessments.The facility did not accurately code section J1300 of Resident # 6's annual MDS for smoking. The facility coded Section A1500 of Resident #27's admission assessment with information that was not available at the time of the completion of the MDS.The facility failed to ensure Residents #29's MDS assessment was accurately coded for Preadmission Screening and Resident Review (PASRR). These failures could place residents at risk for not receiving the appropriate care and services to maintain the highest level of well-being.Findings included: 1.Record review of Resident #6's face sheet dated 07/15/2026 indicated he was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (also known as COPD and refers to a progressive, incurable lung disease that causes restricted air flow and severe breathing difficulties). Record review of an annual MDS assessment dated [DATE] reflected Resident #6 had a BIMS score of 15 indicating his cognition was intact. The same MDS also indicated Resident #6 did not use tobacco. Record review of a list provided by the facility of residents who smoked identified Resident #6 as one of the residents who smoked. Record review of a Baseline Care Plan: Section H: Safety Risks dated 06/30/2025 indicated Resident #6 smoked with supervision. During observations of residents smoking on 07/14/2026 and 07/15/2026 at 01:00 PM, Resident #6 was observed to not be present. During an interview on 07/15/2026 at 01:15 PM, Resident #6 said he smoked sometimes but not very often. He said if he wanted to smoke, he would go outside with the other residents who smoked. During an interview on 07/15/2026 at 01:30 PM, LVN-A said Resident #6 smoked occasionally. 2. Record review of Resident #27's face sheet dated 07/15/2026 indicated he was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included bipolar disorder(a mental health condition characterized by mood swings from extreme to another) and schizophrenia(a chronic, severe brain disorder characterized by an inability to distinguish between reality and imagination). Record review of Section A1500: Preadmission Screening and Resident Review (PASRR) of the admission MDS assessment dated [DATE] indicated Resident #27 was considered by the state level II PASRR process to not have serious mental illness and/or intellectual disability or a related condition. Record review of a PASRR Level I Screening was noted to have not been completed until 01/14/2026. The PASRR Level II Screening was noted to have not been completed until 02/18/2026. The dates of these PASRR Screenings indicated the information on the admission MDS assessment regarding PASRR Screenings was incorrectly documented since the information on the MDS was not available until after the MDS was completed. During an interview on 07/14/2026 at 01:45 PM with the DON, she said the MDS nurse was responsible for completing accurate MDS assessments and the PASRR process. She said the facility did not have an in-house MDS nurse and MDS nurses from sister facilities had been helping with the completion of MDS assessments and PASRR process. She said Resident #6 should have been coded for tobacco use. She said Resident #27's coding of PASRR Screenings was inaccurate since no PASRR Screenings had been done. The DON said she was ultimately responsible for the accuracy of the MDS assessments. The DON said she could not say why Resident #6's and Resident #27's MDS assessments were inaccurately coded because she was not employed at the facility at the time of those MDS assessments. The DON said accurate MDS assessments were important for care planning and reimbursement. During an interview on 07/14/2026 at 03:10 PM, the Regional Nurse Consultant said the MDS coding on Resident #6 and Resident #7's MDS assessments were an oversight that was most likely due to several people assisting with MDS assessments and the PASRR process. 3. Record review of Resident #29's face sheet for July 2026 indicated a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #29 had diagnoses which included bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), anxiety (intense, excessive, and persistent worry and fear about everyday situations), mood disorder (a mental health condition that primarily affects your persistent emotional state), and cerebral palsy (motor disability occurring in childhood with a group of lifelong neurological disorders). Record review of Resident #29's PASRR Level 1 screening completed 12/03/2025 indicated she did not have a primary diagnosis of dementia and was positive for mental illness and intellectual disabilities. Record review of Resident #29's PASRR Evaluation completed 01/06/2026 indicated she was positive for intellectual and developmental disabilities. Record review of Resident #29's admission MDS dated [DATE] Section A1500. Preadmission Screening and Resident Review (PASRR) indicated No if resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. Section I Active Diagnoses under Neurological indicated Cerebral Palsy and under Psychiatric/Mood Disorder indicated the resident had anxiety, depression, and bipolar disorder. During an interview on 07/14/2026 at 2:05 PM, the Regional Nurse Consultant said the facility used the RAI Version 3.0 Manual as the policy for completing MDS assessments. She said Section A 1500 indicated if the resident was positive for mental illness, intellectual disability or developmental disability. She said Section A 1500 for Resident #29 was marked incorrectly as No and should be marked Yes because she was PASRR positive for Intellectual Disabilities and was receiving PASRR specialized services. She said it was important to make sure the PASRR screening information was correct so residents did not miss the opportunity for services and CMS was aware the facility had correctly screened the residents. A review of the October 2024 RAI 3.0 Manual: Section J: Health Conditions indicated the following: Section J of the MDS 3.0 focuses on documenting health conditions that impact a resident's functional status and quality of life. The RAI process has multiple regulatory requirements. Federal regulations at 42 CFR 483.20 (b)(1)(xviii), (g), and (h) require that:(1)the assessment accurately reflects the resident's status.

Based on interview and record review, the facility failed to use the services of a registered nurse for 8 consecutive hours 7 days a week for 2 of 4 quarters of 2026 (Fiscal Year Quarter 2 January 1-March 1) (Fiscal Year Quarter 3 April 1 - June 1) reviewed for RN coverage. The facility did not have RN coverage for 8 consecutive hours on 01/03/2025, 01/04/2026, 01/24/2026, 01/25/2026, 02/07/2026, 02/08/2026, 02/14/2026, 02/15/2026, 03/07/2026, 03/08/2026, 03/15/2026, 03/21/2026, 03/22/2026, 04/04/2026, 04/05/2026, 04/25/2026, 05/02/2026, 05/03/2026, 05/17/2026, 05/31/2026, 06/13/2026, 06/14/2026, 06/21/2026, 06/27/2026, and 06/28/2026.This failure could place residents at risk of lack of nursing oversight and a higher level of care. Findings included:Record review of the CMS PBJ reports indicated Quarter 2 2026 (January 1-March 1) there were no consecutive 8 hours of RN coverage on 01/01/2026 (Thursday); 01/03/2026 (Saturday); 01/04/2026 (Sunday); 01/24/2026 (Saturday); 01/25/2026 (Sunday); 02/07/2026 (Saturday); 02/08/2026 (Sunday); 02/15/2026 (Sunday); 03/07/2026 (Saturday); 03/08/2026 (Sunday); 03/21/2026 (Saturday).Record review of the RN time sheets indicated Quarter 2 2026 (January1 -March1) there were no consecutive 8 hours of RN coverage on 01/03/2025 (Saturday), 01/04/2026 (Sunday), 01/24/2026 (Saturday), 01/25/2026 (Sunday), 02/07/2026 (Saturday), 02/08/2026 (Sunday), 02/14/2026 (Saturday), 02/15/2026 (Sunday), 03/07/2026 (Saturday), 03/08/2026 (Sunday), 03/15/2026 (Sunday), 03/21/2026 (Saturday), and 03/22/2026 (Sunday).Record review of the RN time sheets indicated Quarter 3 2026 (April1 -June 1) there were no consecutive 8 hours of RN coverage on 04/04/2026 (Saturday), 04/05/2026 (Sunday), 04/25/2026 (Saturday), 05/02/2026 (Saturday), 05/03/2026 (Sunday), 05/17/2026 (Sunday), 05/31/2026 (Sunday), 06/13/2026 Saturday), 06/14/2026 (Sunday), 06/21/2026 Sunday), 06/27/2026 (Saturday), and 06/28/2026 (Sunday).During an interview on 07/13/2026 at 3:20 PM the DON said she had been at the facility since 04/15/2026. She said she had 1 RN working as a day shift charge nurse that occasionally worked some weekends. She said usually every other weekend but not always. She said she was in the process of hiring an RN weekend supervisor but the prospective employee had not completed her onboarding yet. She said some weekends RN D worked the day shifts (6AM-6PM) on the weekends and she had 8 consecutive hours of coverage on those weekends. She said some weekends RN D worked the night shift (6PM-6AM) and although she would have over the hours required they would not be consecutive hours. She said some weekends she had no RN coverage and she told the facility staff to call her if they needed her but she was not normally onsite on those weekends. She said it had been difficult to find anyone to work. She said she had interviewed 2 RNs and they both had agreed to hire on at the facility. She said one called back and declined the position and the other had not completed the onboarding. The DON said she would provide time sheet documentation for RN coverage for the months of January, February, March, April, May, June and July 2026.During an interview on 07/15/2026 at 9:30 AM the Regional Nurse Consultant said she was aware they did not have adequate RN coverage that fulfilled the 8 consecutive hours 7 days a week requirement for RN coverage but knew the DON was actively seeking RN applicants.During an interview on 07/15/2026 at 9:35 AM the Administrator said she had been at the facility for one week and was not aware they did not have adequate RN staffing coverage.

Based on interview and record review, the facility failed to inform the resident or resident representative in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers for 1 of 5 residents (Resident #18) reviewed for resident rights. The facility did not obtain written consent for Resident #18's prescription of Ativan (a benzodiazepine medication used to treat anxiety disorders and insomnia) and ensure the responsible party was notified of the medication change. This failure could affect residents who receive psychotropic medications by placing them at risk of receiving medications without informed consent. The findings included: A record review of Resident #18's face sheet dated 07/15/2026 indicated a [AGE] year-old female admitted to the facility 06/17/2022. Resident #18 had diagnoses which included schizophrenia, unspecified (a mental health condition that can result in symptoms including hallucinations, delusions, and disorganized thinking), insomnia, unspecified (a sleep disorder characterized by difficulty falling asleep, staying asleep, or waking up too early and not being able to return to sleep), and major depressive disorder, single episode, severe with psychotic features (a form of depression characterized by low mood, loss of interest, and psychotic symptoms such as delusions or hallucinations). A record review of Resident #18's most recent Quarterly MDS assessment dated [DATE] indicated a BIMS score of 5, which indicated severe cognitive impairment. The MDS indicated Resident #18 was taking an antianxiety medication. A record review of Resident #18's comprehensive care plan indicated on 05/06/2026 Resident #18 used anti-anxiety medications. The care plan indicated Resident #18 would be free from discomfort or adverse reactions related to anti-anxiety therapy through the review date. Interventions included administer anti-anxiety medications as ordered by the physician, monitor/document/report any adverse reactions to anti-anxiety therapy, and monitor/record occurrence for target behavior symptoms (pacing, wandering, disrobing, inappropriate responses to verbal communication, violence/aggression towards staff/others, etc.) and document per facility protocol. A review of Resident #18's medication orders indicated an order dated 05/06/2026 for Ativan 0.5 milligrams 1 tablet by mouth three times a day for anxiety. An interview was attempted with Resident #18 on 07/13/2026 at 10:41 AM and Resident #18 did not respond to questions asked. A record review of Resident #18's electronic medical record on 07/14/2026 at 2:00 PM did not indicate a psychoactive medication consent present for the prescription of Ativan. During an interview on 07/15/2026 at 9:18 AM, Resident #18's representative and medical power of attorney stated she thought staff had called her to discuss a medication to treat anxiety and agitation. During an interview on 07/15/2026 at 9:25 AM, the DON stated she could not find the medication consent for Resident #18's prescription of Ativan, but she would look for it as some consents were still needing to be scanned into the electronic medical records. The DON stated the ADON had been responsible for ensuring psychoactive medication consents were completed, but she had quit about a month ago. The DON stated since the ADON quit she became responsible for ensuring psychoactive medication consents were completed. During an interview on 07/15/2026 at 9:50 AM, the DON stated she could not find a psychoactive medication consent for Resident #18's prescription of Ativan. The DON stated the risk to residents for not having a completed psychoactive medication consent included that it was their right to give their approval to take any medication and know what it was meant to treat. During a record review on 07/15/2026 at 10:11 AM, there were no progress notes evident in Resident #18's electronic medical record that indicated Resident #18's responsible party was notified of Ativan being prescribed. A record review of a progress note dated 05/07/2026 at 5:42 PM written by LVN A indicated a status post 1/3 Ativan 0.5 milligrams three times a day routinely. The progress note indicated Resident #18 had slept off/on most of the shift and had no behaviors nor anxiety noted. The progress note did not indicate if Resident #18's responsible party was notified of the new prescription of Ativan. During an interview on 07/15/2026 at 10:45 AM, LVN A stated she could not find documentation that she notified Resident #18's responsible party of the new prescription of Ativan. LVN A stated she usually did obtain consent from the resident or their responsible party for a new medication and felt like she had done so for Resident #18's prescription of Ativan, but she forgot to document it. LVN A stated the risk to Resident #18 was low as she was being monitored for any side effects, but stated it is their right to be notified of the risks and benefits of any new medication. During an interview on 07/15/2026 at 1:50 PM, the ADM stated when the doctor sent in a new order nursing staff was responsible for obtaining consent and the DON was responsible for overseeing that it was completed appropriately. The ADM stated Resident #18's psychoactive medication consent might have been missed due to the DON being new and she was still implementing new policies and procedures. The ADM stated the previous DON's office had many papers that had not been scanned into the medical record and the consent might have been completed but was misplaced. The ADM stated the risk of not having informed consent when starting a new psychoactive medication included the resident or family not being educated on the side effects or being able to consent to the medication with knowledge of the side effects. A record review of a facility policy, dated July 2022, titled Psychotropic Medication Use indicated the following: Policy Interpretation and Implementation1. A psychotropic medication is any medication that affects brain activity associated with mental processes and behavior. 2. Drugs in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications:a. Anti-psychotics;b. Anti-depressants;c. Anti-anxiety mediations; and d. Hypnotics.3. Residents, families, and/or the representative are involved in the medication management process. Psychotropic medication management includes: a. indications for use; b. dose (including duplicate therapy); c. duration; d. adequate monitoring for efficacy and adverse consequences; and e. preventing, identifying, and responding to adverse consequences.Resident Evaluations .4. Residents (and/or representatives) have the right to decline treatment with psychotropic medications. a. The staff and physician will review with the resident/representative the risks related to not taking the medication as well as appropriate alternatives.

Based on interview and record review, the facility failed to provide evidence of State Level 1 prescreening to determine if a newly admitted resident had or may have had MI, ID, or related condition for 1 of 5 residents (Resident #27) reviewed for the pre-admission screening and resident review (PASRR) program and PASRR assessments and evaluations. The facility failed to ensure Resident #27's PASRR Level 1 screening was completed prior to admission to the facility. This failure could place residents with psychiatric diagnoses at risk of not being properly placed and/or evaluated for PASRR services and potentially not receiving services for care and treatment. Findings included:Record review of a face sheet dated 07/15/2026 indicated Resident #27 was a [AGE] year-old male who admitted to the facility 12/11/2025. He had diagnoses which included bipolar disorder (a mental health condition characterized by mood swings from extreme to another) and schizophrenia(a chronic, severe brain disorder characterized by an inability to distinguish between reality and imagination).Record review of Resident #27's State Level I PASRR process indicated the screening was completed on 01/14/2026 which was 34 (thirty-four) days after being admitted to the facility. Record review of Resident #27's State Level II PASRR process indicated the evaluation was completed on 02/18/2026 which was 52 days after admission. During an interview on 07/14/2026 at 03:07 PM, the Regional Consultant said the PASRR Level I screening was not completed timely. She said there were multiple nurses assisting with the MDS assessments and PASRR process which may have led to the oversight. During an interview on 07/15/2026 at 01:45 PM, the DON said she was not an employee at the time of Resident #27's admission to the facility and could not say why he did not have a PASRR Level I screening prior to admission. The DON said whoever completed the admission MDS assessment should have noticed the PASRR Level I screening had not been done and addressed it. She said the Marketing Director was currently responsible for obtaining PASRR Level I screenings for potential admissions. The DON said she did not know who was responsible for the PASRR process or MDS completion when Resident #27 admitted to the facility. The DON said failure to ensure the PASRR Level I process was followed could result in a resident not being properly placed and potentially not receiving services for which he or she qualified for. Record review of the facility's policy dated 01/20/2026 and titled PASRR indicated the following: The aim of the PASRR program is to identify residents with Mental Illness (MI), Intellectual Disability (ID), or Developmental Disability (DD)/Related Conditions (RC) and to ensure they are properly placed, whether in community or in a Nursing Facility (NF) and to ensure they receive the services they require for their MI, ir ID/DD.The facility Admissions Coordinator or designee will ensure the referring entity provides a copy of the PL1 (PASRR Level 1)upon admission.

Based on interview and record review, the facility failed to develop and implement a baseline care plan within 48 hours of admission that included the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care for 2 of 5 residents (Resident #6 and Resident #27) reviewed for baseline care plans. The facility failed to ensure Resident #6's baseline care plan was completed within 48 hours of admission. The facility failed to ensure Resident #27's baseline care plan was correctly coded for smoking and included instructions for supervision when smoking. These failures could place newly admitted residents at risk of receiving inadequate care and services. Findings included: 1. Record review of Resident #6's face sheet dated 07/15/2026 indicated he was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (also known as COPD and refers to a progressive, incurable lung disease that causes restricted air flow and severe breathing difficulties), congestive heart failure (a chronic condition where the heart does not pump blood as effectively as it should leading to fluid retention), dementia (a decline in cognitive abilities including loss of memory, language, and problem-solving abilities), diabetes (a chronic metabolic disease characterized by high blood sugar levels), and atrial fibrillation (irregular heartbeat which can lead to stroke or heart failure). Record review of Resident #6's baseline care plan dated 06/30/2026 indicated the baseline care plan was completed 6 days after admission and was noted to identify Resident #6 as a smoker. 2. Record review of Resident #27's face sheet dated 07/15/2026 indicated he was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included bipolar disorder(a mental health condition characterized by mood swings from extreme to another), schizophrenia(a chronic, severe brain disorder characterized by an inability to distinguish between reality and imagination), cerebral infarction (a stroke), diabetes, congestive heart failure, and chronic obstructive pulmonary disease. Resident #27 also had a history of smoking. Record review of Resident #27's baseline care plan dated 12/11/2025 indicated Resident #27 was not a smoker. During an interview on 07/13/2026 at 02:40 PM, RN-D said baseline care plans were to be completed within 48 hours of admission and should include directions for providing care specific to each resident's needs such as monitoring a resident for high or low blood sugars or monitoring residents who smoke during smoke breaks. During an interview on 07/14/2026 at 10:15 AM, the DON said she was not employed at the facility when Resident #6 and Resident #27 were admitted to the facility. She said she did not know why Resident #6's baseline care plan was not completed in a timely manner or why Resident #27 had no interventions to address his smoking. She said the baseline care plan served as an initial guide for providing care to a newly admitted resident based on his or her individual needs. She said failure to implement a baseline care plan in a timely manner or failure to accurately identify resident needs could put a resident at risk for not receiving needed care or services. Record review of the facility's policy titled Care Plans-Baseline and dated 2001 and revised March 2022 indicated the following: A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs for 1 of 5 residents (Resident #6) reviewed for care plans. The facility failed to ensure Resident #6's care plan addressed his use of tobacco and non-compliance with the physician's order for fluid restrictions. This failure could place residents who smoke or have orders for fluid restrictions at risk for not receiving care and services to meet medical, mental, psychosocial, and nursing needs. Findings included: Record review of Resident #6's face sheet dated 07/15/2026 indicated he was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (also known as COPD and refers to a progressive, incurable lung disease that causes restricted air flow and severe breathing difficulties), and congestive heart failure (a chronic condition where the heart does not pump blood as effectively as it should leading to fluid retention). Record review of an annual MDS assessment dated [DATE] reflected Resident #6 had a BIMS score of 15 indicating his cognition was intact. Record review of a baseline care plan dated 06/30/2025 indicated Resident #6 smoked and required supervision when smoking. The baseline care plan did not address fluid restrictions. Record review of physician orders dated 07/15/2026 indicated he had an order for fluid restrictions of 1500 cc per 24 hours dated 10/10/2025. Record review of Resident #6's comprehensive care plan with the last revision date of 04/27/2026 indicated there were no concerns or interventions to address smoking nor the physician's order for fluid restrictions. During an interview on 07/15/2026 at 01:30 PM, LVN-A said Resident #6 smoked occasionally, but not very often. She said residents who smoked were supervised by staff when smoking. She said Resident #6 was not compliant with fluid restrictions. She said staff encouraged Resident #6 to limit his fluids. She said Resident #6 had not exhibited any issues with fluid retention that she was aware of. During an interview on 07/15/2026 at 02:45 PM, the DON said Resident #6 was not compliant with fluid restriction orders and had not shown any evidence of fluid retention. She said no resident who smoked was allowed to smoke without staff supervision. The DON said smoking and fluid restrictions should have been addressed on Resident #6's care plan. She said care plans were a joint effort of the interdisciplinary team and she was ultimately responsible for ensuring the comprehensive care plan included interventions to address potential problem areas and conditions. The DON said failure to include interventions in the care plan that address problem areas or conditions could place a resident at risk for not receiving needed care or services. Record review of the facility's policy titled Care Plans, Comprehensive Person-Centered and dated as revised March 2022 indicated the following: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident.7.The comprehensive, person-centered care plan: .b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, .e. reflects currently recognized standards of practice for problem areas and conditions.

Based on observation, interview, and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 2 of 3 residents (Resident #6 and Resident #27) reviewed for accident hazards. The facility failed to assess Resident #6 and Resident #27 for safety when smoking. This failure could place residents at risk of accidents and injuries. Findings included: Record review of Resident #6's face sheet dated 07/15/2026 indicated he was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included dementia (a decline in cognitive abilities including loss of memory, language, and problem-solving abilities) and chronic obstructive pulmonary disease (also known as COPD and refers to a progressive, incurable lung disease that causes restricted air flow and severe breathing difficulties). Record review of an annual MDS assessment dated [DATE] reflected Resident #6 had a BIMS score of 15 indicating his cognition was intact. He was ambulatory and able to voice needs. A record review of physician orders dated 07/15/2026 indicated Resident #6 did not have any orders related to smoking. Record review of a list provided by the facility of residents who smoked identified Resident #6 as one of the residents who smoked cigarettes. Record review of Resident #6's undated comprehensive care plan indicated smoking was not addressed. The care plan did not include any information regarding Resident #6's smoking status nor did it include any safety needs to prevent injury. A record review of Resident #6's medical records did not reflect Resident #6 had been assessed for safe smoking. During observations of residents smoking on 07/14/2026 and 07/15/2026 at 01:00 PM, Resident #6 was not present. During an interview on 07/15/2026 at 01:15 PM, Resident #6 said he smoked sometimes. He said if he wanted to smoke, he would go outside with the other residents who smoked. 2. Record review of Resident #27's face sheet dated 07/15/2026 indicated he was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included bipolar disorder(a mental health condition characterized by mood swings from extreme to another), schizophrenia(a chronic, severe brain disorder characterized by an inability to distinguish between reality and imagination), and chronic obstructive pulmonary disease (also known as COPD and refers to a progressive, incurable lung disease that causes restricted air flow and severe breathing difficulties). Record review of a quarterly MDS assessment dated [DATE] indicated Resident had a BIMS score of 9 indicating his cognition was moderately impaired. The MDS also noted Resident #27 was a tobacco user. A record review of physician orders dated 07/15/2026 indicated Resident #27 did not have any orders related to smoking. Record review of a list provided by the facility of residents who smoked identified Resident #27 as one of the residents who smoked cigarettes. Record review of Resident #27's comprehensive care plan indicated Resident #6 smoked cigarettes with interventions to educate Resident on the facility's tobacco/smoking policy and orient Resident to smoking times and procedures. The care plan did not include any information regarding Resident #6's smoking status nor did it include any safety needs to prevent injury. A record review of Resident #27's medical records did not reflect Resident #27 had been assessed for safe smokingDuring observations of residents smoking on 07/14/2026 and 07/15/2026 at 01:00 PM, Resident #27 was sitting in a chair and smoking a cigarette. He was observed to hold the cigarette safely and use the ashtray appropriately. Facility staff were noted to be present in the area and controlled the dispensing of cigarettes and use of lighters. During an interview on 12/09/2024 at 11:20 AM, Resident #27 said he had smoked a long time and had never burned himself. He said he was going inside and could not talk anymore. During an interview on 07/15/2026 at 01:30 PM, LVN-A said Resident #6 smoked occasionally, but not very often. LVN-A said Resident #27 smoked routinely per the smoking times schedule. She said residents were supervised by staff during the smoking times. She said residents were not allowed to smoke unsupervised. She said she did not know of any resident who smoked needing more than staff supervision when smoking. She said she did not know who performed the smoking assessments. During an interview on 07/14/2026 at 02:10 PM, the DON said she did not find a smoking assessment for Resident #6 nor Resident 27. She said the smoking assessment was not automatically triggered on admission to the facility. She said when a nurse finds that a resident smokes during the admission assessment, the nurse should complete a smoking assessment. She said she was not employed by the facility at the time Resident #6 and Resident #27 admitted to the facility and did not know why they had not been assessed for safe smoking. The DON said smoking assessments were important for identifying what safety needs were needed to reduce the risks of burns when a resident is smoking. Record review of the facility's policy titled Smoking Policy - Residents and dated October 2022 indicated the following: This facility shall establish and maintain safe resident smoking practices.7. The resident will be evaluated on admission to determine if he or she is a smoker or non-smoker. If a smoker or smokeless tobacco user, the evaluation will include: a) Current level of tobacco consumption . d) Ability to smoke safely with or without supervision (per a completed Smoking Assessment). 9. A resident's ability to smoke or chew tobacco safely will be re-evaluated quarterly, upon a significant change (physical or cognitive) and as determined by staff.

Based on observation, interview and record review, the facility failed to ensure resident rooms measured at least 80 square feet per resident in multiple resident rooms and at least 100 square feet in single resident rooms for 2 of 10 resident rooms (Resident room [ROOM NUMBER] and 311) reviewed for square footage.The facility failed to provide 80 square feet per resident for a room certified for 4 residents and provide 100 square feet for a room certified as a private room. The failure could place residents at risk of not having adequate space to meet their needs.Findings included:During an observation on 07/14/2026 at 9:55 AM, it was observed that no residents were residing in room [ROOM NUMBER] and no residents were residing in room [ROOM NUMBER].During an interview on 0714/2026 at 10:00 AM, the Administrator said she was not aware the facility had any rooms with room waivers. She said she had been at the facility about a week. She was informed rooms [ROOM NUMBERS] had room waivers in previous years. She was told resident rooms [ROOM NUMBERS] still required room waivers and room [ROOM NUMBER] was certified for 4 residents and measured 74 square feet per resident and room [ROOM NUMBER] was certified as a private room and measured 81 feet instead of 100 square feet. She said room [ROOM NUMBER] was used as a staff break room. She said there were no residents currently residing in those rooms. During an interview on 07/15/2026 at 9:40 AM, the Administrator said she had not found any physical papers indicating a room waiver had been filed last year. She said she also had a waiver from life safety code and was told by life safety code all she had to do was on the plan of correction indicate she was requesting the waiver and indicate no end date so that it went on forever.Record review of the bed classification form dated 07/13/2026 indicated room [ROOM NUMBER] was certified for 4 residents and room [ROOM NUMBER] was certified for 1 resident.

Based on interview and record review, the facility failed to ensure the resident and/or representative had the right to participate in the development and implementation of his or her person-centered care plan for 1 of 6 residents (Resident #1) reviewed for the right to participate in planning care. The facility failed to ensure Resident #1 and Resident #1's representatives were included in the development and implementation of Resident #1's baseline, comprehensive, and discharge care plans. This failure could place residents at risk of not receiving adequate and individualized care while a resident of the facility and after discharge from the facility. Findings included: A record review of Resident #1's face sheet dated 05/21/2026 indicated he was a [AGE] year-old male who admitted to the facility 04/01/2026. He had diagnoses which included sepsis with septic shock (body's extreme, life threatening response to an infection characterized by dangerously low blood pressure and potential organ failure - considered a medical emergency), diabetes, atrial fibrillation (an irregular heart rhythm where the heart's upper chambers beat rapidly and out of sync with the lower chambers), and bacterial pneumonia (a serious lung infection that causes the air sacs in one or both lungs to fill with fluid or pus). Further review of the face sheet indicated Resident #1's spouse was the responsible party and first contact. Resident #1's son was listed as the second contact and the Resident's 2 (two daughters) were also listed as contacts. Resident #1 discharged from the facility on 04/16/2026. A record review of an admission MDS dated [DATE] indicated Resident #1 had a BIMS score of 13 which indicated his cognition was intact. He was able to feed himself, mobile via wheelchair, and was frequently incontinent of urine. A record review of Resident #1's physician's orders dated 04/14/2026 reflected the following orders:1.Consult with wound care provider for skin and wound conditions/prevention dated 04/01/26.2.Pressure reducing mattress to bed dated 04/01/2026.3.Resident to have heels offloaded while in bed every shift for DTI bilateral heels dated 04/09/2026.4.Cleanse bilateral heels daily and as needed with wound cleanser, apply betadine to heels, leave open to air and monitor for signs/symptoms of breakdown dated and offload heels with boots dated 04/14/2026. A record review of Resident #1's baseline care plan dated 04/01/2026 indicated his preference for notification of updates to the care plan was during normal care plan meetings. The signature page which included sections for the signature of Resident #1, his representatives, and the person completing the care plan were blank. A record review of Resident #1's comprehensive care plan (initiated on 04/08/2026) indicated concerns which included a full code status, visual impairment, DTI of the bilateral heels (a form of pressure ulcer on both heels), risk for infection, risk for impaired skin integrity, physical mobility weakness, and diabetes. The care plan included interventions to address these concerns. The signature page was blank. There was no documentation to indicate the comprehensive care plan had been reviewed with Resident #1 or his representative. A record review of Resident #1's discharge plan dated 04/14/2026 indicated it had not been signed by Resident #1 nor the representatives. During an interview on 05/20/2026 at 12:18 PM with one of Resident #1's representatives, Representative A, she said she requested a care plan meeting and a discharge care plan meeting a few days before he was discharged but was never notified of one. During an interview with the DON on 05/21/2026 at 10:01 AM, she said Resident #1 was discharged from the facility 2 days after she began working at the facility and was not aware there had been no care plan meetings with Resident #1 and his representatives. She said the SW handled the scheduling of care plan meetings. During an interview with the SW on 04/21/2026 at 10:12 AM, she said she scheduled the quarterly and comprehensive care plan meetings. She said Resident #1 discharged home before she could schedule a comprehensive care plan meeting with Resident #1 and his representatives. She said the nursing staff handled the baseline and discharge care plans. During an interview with the DON on 05/21/2026 at 10:28 AM, she said the nurses should complete and print the baseline and discharge care plans, review them with the Resident and/or representative, and have the Resident and/or representative sign them. She said after the care plans were signed, the nurse should give the resident and/or representative a copy and scan the original into the computer system. The DON said the care plans were important for ensuring the residents' needs were adequately and consistently met. She said the inclusion of the resident and/or representatives helped to ensure the care plans were individualized and communicated to promote the highest level of well-being possible. Record review of the facility's policy entitled Resident Rights and dated October 2022 indicated the following: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents' right to:p.be informed of, and participate in, his or her care planning and treatment.

Based on interview and record review, the facility failed to report the results of an investigation in accordance with State law, including to the State Survey agency, within 5 working days of the incident for 1 of 4 incidents reviewed for reporting. The facility failed to provide the State Survey Agency with a report of the results of an investigation of an allegation of abuse within 5 working days of the incident. The facility reported an allegation of abuse regarding Resident #2 on 05/06/2026. This failure could place residents at risk for abuse if alleged violations are verified and appropriate corrective actions are not taken. Findings included: A record review of a face sheet dated 05/21/2026 indicated Resident #2 was a [AGE] year-old female who admitted to the facility on [DATE]. She had diagnoses which included lupus erythematosus (chronic, inflammatory disease where the body's immune system mistakenly attacks healthy cells and tissues), bipolar disorder, anxiety, factitious disorder imposed on another (a severe form of abuse in which a caregiver fabricates, exaggerates, or induces illness in a dependent), diabetes, chronic kidney disease, and pneumonia. A record review of an annual MDS dated [DATE] indicated Resident #2 had a BIMS score of 15 indicating her cognition to be intact. A record review of progress notes dated 05/06/2026 indicated Resident #2 was sent to the hospital ER where she was diagnosed with pneumonia and returned to the facility with orders for antibiotic therapy. A review of a facility reported incident dated 05/06/2026 indicated the DON received a call from the hospital case manager who said that that while at the hospital ER, Resident #2 said the facility's Administrator used racial slurs including the N word. Upon receiving the allegation of verbal abuse, the Administrator was suspended and sent home, and the Regional Nurse Consultant reported the incident to the appropriate state agency. A review of the facility's investigation dated 05/06/2026 indicated the allegation of verbal abuse was investigated by the DON and the Regional Nurse Consultant. The allegation of verbal abuse was unsubstantiated, and the Administrator was allowed to return to work. A record review, completed on 05/20/2026 at 11:15 AM, of the TULIP (Texas Unified Licensure Information Portal, an online system for submitting long-term licensure applications for all provider types regulated by long-term regulatory agencies) system revealed that no provider Investigation Report (Form 3613-A) had been filed in the system. The facility filed the facility reported incident and CII Self-Report Template on 05/06/2026. During an interview on 05/20/2026 at 11:20 AM, the Administrator said she did not submit a report for the findings of the allegation because she was the alleged perpetrator and was not a part of the investigation. An attempt to interview the Regional Nurse Consultant by phone was unsuccessful during the investigation. A record review of the facility's policy titled Abuse, Neglect, Exploitation or Misappropriation -Reporting and Investigating and dated September 2022 indicated the following: Policy StatementAll reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Investigating Allegations: 7. All allegations are thoroughly investigated. The administrator initiates investigations. 8. Investigations may be assigned to an individual trained in reviewing, investigating, and reporting such allegations. Follow-Up Report1.Within five (5) business days of the incident, the administrator will provide a follow-up investigation report.

Based on observations, interviews, and record reviews, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 2 medication carts (Nurses cart) reviewed for pharmacy services. The facility failed to ensure the nursing staff responsible for the safekeeping of narcotics performed and documented change of shift narcotic counts. This failure could place residents at risk for loss of medications and possible drug diversion. Findings included: A record review of a face sheet dated 05/21/2026 indicated Resident #3 was a [AGE] year-old male who admitted to the facility on [DATE]. He had diagnoses which included spinal stenosis (the narrowing of the spaces within the spine which puts pressure on the spinal cord and nerves), chronic neck and back pain, lumbar radiculopathy (irritation or compression of a nerve root in the lower back causing pain, tingling, and weakness that radiates down the buttock and leg), cervical radiculopathy (compressed nerve root in the neck causing pain in the neck), left shoulder pain, chronic neck and back pain, and post spinal cord surgery. A record review of an admission MDS dated [DATE] noted Resident #3 had a BIMS score of 12 which indicated he had moderately impaired cognition. He was able to feed himself, ambulate short distances, used a wheelchair, and was continent of bowel and bladder. A review of Resident #3's physician's orders dated 05/21/2026 indicated he had an order dated 04/30/2026 for Hydrocodone-Acetaminophen 10-325 mg: 1 tablet every 6 hours as needed for chest pain related to spinal stenosis. A review of an undated Controlled Medication Administration Record indicated that on 05/06/2026 the facility received a bottle of 29 Hydrocodone 10-325mg tablets from Resident #3's home. Resident #3 was given 1 (one) Hydrocodone tablet on 05/07/2026 and 1 (one) tablet on 05/08/2026. A review of a pharmacy packing slip dated 05/03/2026 indicated a card of 25 Hydrocodone-Acetaminophen 10-325mg tablets was delivered to the facility and signed for by RN-A on 05/03/2026 at 07:28 PM. During an observation and interview on 05/20/2026 at 11:30 AM, LVN-D was noted standing at the Nurses Cart located in the medication room. LVN-D said the Nurses Cart contained narcotics for PRN use. LVN-D said the on-coming and off-going nurses were supposed to count the narcotics at every change of shift. She said it was important to count narcotics every time the keys to the cart were passed from one person to another to reduce the risk of missing, lost, or unaccounted for narcotics. A review of the Nurse Cart's Narcotic Release and Acceptance of Narcotic Inventory sheet dated May 2026 revealed there were 4 (four) missing signature entries on the following dates:1)May 10, 2026 - No signature of the 6 AM nurse to indicate she performed a narcotic count at the end of her shift with the nurse coming on duty at 6 PM.2) May 14, 2026 - No signature of the 6 AM nurse to indicate she performed a narcotic count at the beginning of her shift with the nurse going off duty at 6 AM.3) May 19, 2026 - No signature of the 6 AM nurse to indicate she performed a narcotic count at the beginning of her shift with the nurse going off duty at 6 AM4) May 19, 2026 - No signature of the 6AM nurse to indicate she performed a narcotic count with the nurse coming on duty at 6PM LVN-D said a card of 25 (twenty-five) hydrocodone tablets came up missing while she was off from work earlier in the month May 2026. She said the May 2026 Narcotic Inventory sheets had several blank signature spots on it which made it look like change of shift counts had not been done. LVN-D said the nurses were in-serviced on performing narcotic counts at change of shift and signing the Nurse release and Acceptance of Narcotic Inventory. During an interview on 05/21/2026 at 09:20 AM, LVN-B said she relieved RN-A on the morning of 05/04/2026 and the 2 (two) of them counted the narcotics. She said she noted Resident #3's new card of 25 Hydrocodone and wrote Use Bottle First on the corresponding Narcotic Count sheet of the card. LVN-B said the card of Hydrocodone and the corresponding count sheet were in the cart when she counted narcotics with the night nurse the next morning (May 5, 2026) when she came to work and the card of Hydrocodone was there when she counted with LVN-C that evening at the end of her shift. LVN-B said she was off and did not work on May 6 and May 7, 2026. LVN-B said she returned to work on the morning of May 8, 2026 and noted the card of Hydrocodone 10-325mg tablets and the corresponding count sheet were missing when she counted the narcotics with the night nurse, RN-A. She said she noted it was missing because she remembered writing Use Bottle First on the count sheet. She said she searched the Nurses' cart, the Medication Aides' cart and the medication room and when she did not locate the narcotic, she notified the DON. LVN-B said the 4 (four) missing signature entries after the date of the in-service on May 2026 Nurse Release and Acceptance of Narcotic Inventory sheet were hers. She said she performed the change of shift narcotic counts but forgot to sign the sheet. LVN-B said the task of performing change of shift narcotic counts was important for safeguarding the narcotics and reducing the risk for missing or unaccounted for narcotics. During an interview on 05/21/2026 at 10:20 AM, RN-A said she received a card of 25 Hydrocodone-Acetaminophen 10-325mg for Resident #3 on the evening of 05/03/2025. She said the card of Hydrocodone was there the next morning (May 4, 2026) when she counted with the morning nurse, LVN-B. RN-A said she was off 2 (two) nights and returned to work the evening of May 7, 2026. She said she relieved LVN-D. She said she and LVN-D did not perform a change of shift narcotic count. RN-A said she did not have a reason for not performing a change of shift count. She said she should have counted the narcotics with the off-going nurse. RN-A said that failing to perform the change of shift narcotic count with the LVN-D meant she could not prove what was or was not on the cart when she took possession of it. RN-A said she and LVN-B performed a change of shift narcotic count the next morning when LVN-B came into work. RN-A said LVN-B asked about the card of Hydrocodone tablets belonging to Resident #3. She said LVN-B said she remembered the card of Hydrocodone because she had written a note on the count sheet to remind everyone to use the bottle of tablets first. RN-A said she was upset with herself for not performing a narcotic count when she came to work the night before. RN-A said she and the other nurses had been in-serviced on performing change of shift narcotic counts and signing the Nurse Release and Acceptance of Narcotic Inventory sheet During an interview with Resident #3 on 06/20/2026 at 10:51AM, he said he was aware of the missing Hydrocodone tablets. He said he had not missed any doses of pain medication, and the nurses had promptly responded to his request for pain medication. Resident #3 said the facility replaced his missing tablets. During an interview on 05/21/2026 at 11:00 AM, the DON said she was made aware that a card of 25 Hydrocodone-Acetaminophen 10-325mg tablets and the corresponding Controlled Medication Administration Record were missing on 05/08/2026. She said a search for the drug was done but the drug was not found. She said she noted several missing signatures from 05/01/2026 through 05/07/2026 on the Nurse Release and Acceptance of Narcotic Inventory sheet. The DON said she made a copy of the sheet with the missing signatures but could not locate it. She said she audited all the carts and medication room and found no other discrepancies. When shown the May 2026 Nurse Release and Acceptance of Narcotic Inventory, the DON said the missing signatures from 05/01/2026 through 05/07/2026 had been filled in. The DON said she could not remember which signatures had been missing and were now filled in. She said she in-serviced the nurses on performing change of shift narcotic counts and signing the count sheet. The DON said she was responsible for ensuring the nurses performed and documented change of shift narcotic counts. When shown the 4 (four) missing signatures for the 05/10/2026 6PM off-going nurse, 05/15/2026 6AM on-coming nurse, and 05/19/2026 6PM on-coming and 6PM off-going nurses, the DON said the missing signatures implied the change of shift narcotic counts had not been done and the risk for loss of medications or drug diversion was still a concern. A review of an in-service training report dated 05/08/2026 indicated nursing staff were in-serviced on performing change of shift narcotic counts. A review of the facility's policy dated November 2022 and titled Controlled Substances indicated the following: Dispensing and Reconciling Controlled Substances1.Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up.3. Nursing staff count controlled medication inventory at the end of each shift, using these records to reconcile the inventory count.4. The nurse coming on duty and the nurse going off duty make the count together and document and report any discrepancies to the director of nursing services.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 staff (Treatment Nurse) and 1 of 1 resident (Resident #1) reviewed for infection control. The facility failed to ensure the Treatment Nurse performed appropriate glove changes and hand hygiene between glove changes while performing wound care on Resident #1 on 12/12/25. This failure could place residents at risk for cross-contamination, spread of infection and could potentially affect all others in the building. Findings included: During an observation on 12/12/25 at 10:07 a.m., the Treatment Nurse did not perform hand hygiene, applied clean gloves, entered Resident #1's room, cleansed the bedside table, laid down a barrier (a protective pad to keep wound care supplies clean), set her supplies on top of the barrier, and removed her gloves. The Treatment Nurse did not perform hand hygiene and applied clean gloves. The Treatment Nurse removed the dirty dressing from Resident #1's sacral area (triangular-shaped bone at the base of the spine that supports the upper body's weight while sitting), removed her gloves, did not perform hand hygiene, and applied clean gloves. The Treatment Nurse cleansed the wound to Resident #1's sacral area, did not change gloves and did not perform hand hygiene. The Treatment Nurse applied collagen powder (a powder that forms a protective gel and creates a moist environment to speed up wound healing for chronic wounds) to Resident #1's wound on her sacral area and covered with a bordered dressing (an absorptive dressing consisting of three layers). The Treatment Nurse did not change gloves or perform hand hygiene. The Treatment Nurse removed the sock from Resident #1's right foot and observed the wound/discolored area to Resident #1's right heel. The Treatment Nurse applied betadine to Resident #1's right heel. The Treatment Nurse removed her gloves, did not perform hand hygiene, gathered her trash, exited the room, disposed of her trash, got a clean blanket off the linen cart and handed it to a CNA (name unknown), and then performed hand hygiene. During an interview on 12/12/25 at 10:32 a.m., the Treatment Nurse said she had received training on wound care from the DON. The Treatment Nurse said she usually performed hand hygiene prior to entering a resident room and upon exiting a resident room. The Treatment Nurse said glove changes should be performed after removing a dirty dressing and when going from one wound to another. The Treatment Nurse said she did not routinely perform hand hygiene between glove changes. The Treatment Nurse said the importance of proper hand hygiene and glove changes was infection control. During an interview on 12/12/25 at 12:20 p.m., the DON said she expected staff to perform hand hygiene before providing care, during care, after care, and any time gloves were changed. The DON said gloves should be changed when going from a dirty area to a clean area, after every step in providing care such as removing dressing, cleansing a wound, and then putting the wound treatment and dressing on a wound, and when going from one wound to another wound. The DON said the importance of appropriate glove changes and hand hygiene was to prevent infections and cross contamination. Record review of the facility's Wound Care policy, last revised October 2010, indicated, The purpose of this procedure is to provide guidelines for the care of wounds and promote healing .Steps in the Procedure.2. Wash and dry hand thoroughly.4. Put on exam gloves. Loosen tape and remove dressing. 5. Pull glove over dressing and discard into appropriate receptable. Wash and dry your hands thoroughly (hand sanitizer can be used). 6. Put on gloves.16. Discard disposable items into the designated container. Discard all soiled laundry, linens, towels, and washcloths into the soiled laundry container. Remove disposable gloves and discard into designated container. Wash and dry your hands thoroughly .23. Wash and dry your hands thoroughly. Record review of the facility's Handwashing/Hand Hygiene policy, last revised October 2023, The facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. Administrative Practices to Promote Hand Hygiene.2. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors.Indications for Hand Hygiene 1. Hand Hygiene is indicated: a. immediately before touching a resident.c. after contact with blood, body fluids, or contaminated surfaces; d. after touching a resident.f/ before moving from work on a soiled body site to a clean body site on the same residents; and g. immediately after glove removal. 2. Use an alcohol-based hand rub containing at least 60% alcohol for most clinical situations.

Based on record review and staff interviews, the facility failed to ensure that residents were free of significant medication errors for 1 of 2 residents (Residents #1) reviewed for pharmacy. The facility failed to ensure oral antibiotic medication was administered to Resident #1 as ordered, resulting in a medication error. As a result of incorrect medication entry, Resident #1 did not receive 6- days of prescribed oral antibiotic, specifically, (Sulfamethoxazole-Trimethoprim oral table 400-80 MG Bactrim), as ordered following hospitalization for sepsis and ureteral stent placement. This failure does not ensure that residents receive necessary treatment to prevent potential decline or worsening of infection. Findings included: A review of Resident #1's face sheet dated 11/20/2024 revealed he was a [AGE] year-old male initially admitted on [DATE] diagnoses of cerebrovascular disease (conditions affecting the blood vessels in the brain), cystostomy (surgery of the bladder to remove bladder stones, clots, tumors, or other obstruction), cystitis with hematuria, mixed incontinence, urinary stents, calculus of kidney, retention of urine, vascular dementia, anxiety, muscle weakness and difficulty in walking. A review of Resident #1's, quarterly MDS section C dated 10/1/2025, revealed a BIMS score of 14 dated 10/02/2025, which indicated he was cognitively intact. A review of Resident #1's medical records revealed that the resident was admitted to the hospital on [DATE] and discharged back to the facility on [DATE] following treatment for sepsis and the placement of a urethral stent. A review of Resident #1's nurse's re-admission notes dated 09/25/2025 at 7:20 P.M., revealed a clarification of the medication order for Sulfamethoxazole-Trimethoprim oral tablet 400-80 MG, by mouth, twice daily for seven days. The HS (bedtime) dose was administered at the hospital prior to discharge. A Review of Resident #1's physician orders dated 09/25/2025, revealed that the physician order was incorrectly transcribed by LPN A, entering a start date of 10/09/2025 and an end date of 10/02/2025. A review of Resident #1's nurse's notes dated 09/26/2025 during the early morning hours revealed that the resident was sent back to the hospital for replacement of a urinary catheter by a Urologist. The review further indicated that the catheter had not been replaced during the initial emergency room visit. A review of Resident #1's nurse's readmission notes dated 09/26/2025 02:00AM revealed that under Special Care it was documented that the resident was currently on antibiotics, listed as Sulfamethoxazole-Trimethoprim oral tablet 400-80 MG, Bid X7 days. The notes further indicated that the urinary catheter was intact and that the urine appeared clear and yellow in color, with no urinary complaints reported. A further review of the provider's order dated 10/2/2025 revealed: Related diagnosis associated with the antibiotic order: sepsis unspecified organism, urinary retention, and urinary stent placement. A new order for Sulfamethoxazole-Trimethoprim oral tablet 400-80 MG, Bid X 7 days for treatment of sepsis, with a start date of 10/2/205 and an end date 10/9/2025. Documentation indicated that the oral antibiotic was not administered between 09/26/2025 and 10/01/2025. A review of Resident #1's Medication Administration Record (MAR) showed that the antibiotic was scheduled to begin at 9:00PM on 10/02/2025. The Director of Nursing (DON) verified that the staff nurse, LVN A entered an incorrect medication start date, which resulted in a delay in treatment. A review of the facility progress notes assessment dated from 09/26/2025 to 11/20/2025, revealed documentation of no fever, no pain discomfort related to foley, and urine color noted clear since readmission to facility on 09/26/2025. A review of the Hospice Nurse visit documentation on 09/29/25 indicated Indwelling Catheter Assessment: No problems noted or verbalized. Drainage system: Bedside drainage, date last changed 09/26/2025, urine characteristics clear /yellow, odor slight. Clinical Findings: Genitourinary No problems noted or verbalized. On 11/20/2025 at 9:30A.M., observed and interviewed Resident # 1 was in his room seated in a wheelchair watching, the resident is interview able, alert and oriented. Resident # 1 was fully dressed, clean and well groomed, bed in low position, water at bedside, call light was in reach. Resident #1 denied abuse or neglect and said he still had his foley but currently there were no issues with his foley. On 11/20/2025 at 2:00P.M., an interview with the DON revealed that the intent of the provider's order was for the resident to begin the next dose of Sulfamethoxazole-Trimethoprim Bactrim orally upon return to the facility on [DATE]. The DON confirmed that the resident should had started the antibiotic immediately after re-admission from the hospital. The DON further stated, she was unsure of how the medication error was discovered, she revealed she was not the DON at the time of discovery. The DON said she was contacted by the VA case manager for clarification as to why the doctor re-ordered the Bactrim to re-start on 10/2/2025. The DON stated the staff nurse entered the wrong date and the veteran (Resident did not start the antibiotic). The DON stated the doctor was notified of the incorrect transcribe start day and immediately re-ordered the po antibiotic Bactrim. On 11/24/2025 at 1:30 P.M., an interview with the VA RN case manager said, that during a chart review, it was noted that Resident #1 had a new order for Bactrim orally for sepsis dated 10/02/25. The VA case manager said she requested clarification as to why the Doctor had re-ordered the Bactrim PO. The VA case manager said the DON reported that the that the intent of the provider's order was for the resident to begin the next dose of Sulfamethoxazole-Trimethoprim Bactrim orally upon return to the facility on [DATE]. She stated, the DON said that the staff nurse LVN A entered the incorrect start date and failed to initiate the next dose of antibiotic. After notifying the physician, the medication was scheduled to start at 9:00P.M. on 10/2/2025. As a result, Resident #1 missed six days of antibiotic therapy following hospitalization for post-sepsis treatment and ureteral stent placement. On 11/24/2025 1:45 P.M., an attempt was made to contact LVN A, however there was no answer. A message was left requesting a return call to the State Surveyor phone number, but no return call was received during the investigation. On 11/24/2025 at 2:00 P.M., interview with the Hospice RN said, Resident #1 had a history of chronic pain related to a prior electrocution injury, which contributed to ongoing pain and discomfort. The hospice RN said that the resident exhibited no fever or pain associated with the catheter and reported no urinary discomfort. She confirmed that the urinary catheter was intact, and the urine was clear and yellow in color, with no urinary complaints noted. On 11/24/2024 at 2:30 P.M., interview with the DON revealed that the original order received from the hospital, and that the admitting staff nurse is responsible for entering all into orders into the system. The DON stated the facility's process for verifying medication orders upon readmission is the responsibility of ADON and DON, who are expected to review all orders entered. The DON reported that LVN A had been employed at the facility since 11/20/2012 and had no prior disciplinary action in her personnel file. She further stated that nursing staff had been educated, and re-educated on receiving orders, accurate medication transcription, medication administration, documentation, and antibiotic stewardship. The DON added that an Action Plan dated 10/2/2025 had been implemented, with ongoing monitoring by the DON and ADON, and review through QAPI every three months. Review of facility policy for documentation of Medication Administration, Antibiotic Stewardship, and Abuse & Neglect, revealed all seven (7) elements were addressed: Screening, Training, Prevention, Identification, Investigation, Protection and Reporting. There were no concerns with facility policy. In-services were reviewed and were compliant.

Based on interview and record review, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 2 of 7 (Resident #1 and Resident #2) residents reviewed for quality of care. The facility failed to ensure Resident #1's wound care orders were implemented on 9/4/25 Wound Care NP's orders. The facility failed to ensure Resident #1 and Resident #2 received proper wound care to prevent deterioration and infection to their surgical wounds. The facility failed to ensure Resident #2's wound care orders were implemented on 9/11/25 and changed on 9/18/25 per the Wound Care NP's orders. This failure resulted in an identification of an Immediate Jeopardy (IJ) at 2:20 p.m. on 9/24/25. While the IJ was removed on 9/25/25, the facility remained out of compliance with a scope identified as patterned and a severity level of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could result in residents with surgical wounds of not having their treatments performed as ordered, wounds becoming infected wounds, and decreased wound healing.Findings Included: 1. Record review of the face sheet dated 9/23/25 indicated Resident #1 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including orthopedic aftercare following surgical amputation (surgical procedure where a body part, such as a limb, finger, or toe is removed), right below the knee amputation, diabetes, peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and hypertension (elevated blood pressure). Record review of the MDS dated [DATE] indicated Resident #1 understood others and was understood by others. The MDS indicated Resident #1 had a BIMS score of 15 and was cognitively intact. The MDS indicated Resident #1 had a surgical wound. Record review of the care plan initiated on 9/16/25 indicated Resident #1 had a recent right below the knee amputation and was at risk for phantom pain (a painful perception an individual experiences relating to a limb or organ that is not physically part of their body), increase in disturbed self-image, increase in depression, and increase in need for assistance with ADLs. The care plan indicated Resident #1 had interventions in place including wound care/dressing changed to be performed to the stump/amputation area per physician orders. Record review of the physician orders which include active, completed, and discontinued order dated 9/23/25 indicated Resident #1 had an order to cleanse the wound on the amputated right knee with wound cleanser, cover with xeroform (a petroleum-based gauze), and cover with dry dressing starting 9/22/25. The physician orders did not indicate Resident #1 had any other wound care orders prior to 9/22/25. The physician orders indicated Resident #1 had an order for Cleocin ((Clindamycin) an antibiotic to treat infection) 150mg 2 capsules 3 times a day related to acquired absence of right leg below the knee. Record review of the TAR dated 9/2025 indicated Resident #1 had not received any wound care in the month of September 2025. The TAR indicated on 9/22/25 Resident #1 did not receive wound care due to being hospitalized . Record review of the Wound Care NP's progress note dated 9/4/25 indicated Resident #1's right leg amputation site had a 100% epithelial ((a wound in final stages of healing) with serosanguineous (a thin, watery discharge that is a mixture of pale yellow, clear liquid and blood) drainage. The progress not indicated Resident #1 had an order to cleanse the surgical site with wound cleanser, apply xeroform, and cover with dry dressing 3 times a week and as needed. Record review of a picture dated 9/4/25 indicated Resident #1's surgical amputation site was well approximated with minor bruising. Record review of the Wound Care NP's progress note dated 9/11/25 indicated Resident #1's right leg amputation site had a 100% epithelial ((a wound in final stages of healing) with serosanguineous (a thin, watery discharge that is a mixture of pale yellow, clear liquid and blood) drainage. The progress not indicated Resident #1 had an order to cleanse the surgical site with wound cleanser, apply xeroform, and cover with dry dressing every other day and as needed. Record review of a picture dated 9/11/25 indicated Resident #1's surgical wound site was well approximated with redness up the leg from the site to the knee. Record review of the Wound Care NP's progress note dated 9/18/25 indicated Resident #1's right leg amputation site had a 100% epithelial ((a wound in final stages of healing) with serosanguineous (a thin, watery discharge that is a mixture of pale yellow, clear liquid and blood) drainage. The progress not indicated Resident #1 had an order to cleanse the surgical site with wound cleanser, apply xeroform, and cover with dry dressing every other day and as needed. Record review of a picture dated 9/18/25 indicated Resident #1's surgical wound site was well approximated with eschar (thick, black, adherent crust of dead tissue) in several different areas near the surgical incision. Record review of the Vascular Surgery NP's progress note dated 9/19/25 indicated Resident #1 had an order for Clindamycin (Cleocin) 300mg three times a day for 10 days with diagnosis of right below the knee amputation. During an interview on 9/23/25 at 12:35 p.m. the DON said she did not know why wound care on Resident #1 was not performed or documented. The DON said the wound care was being done and just because it was not documented, or the orders were not put in does not mean it was not being performed. The DON said the importance of ensuring wound care was performed as ordered was patient care. The DON said she was unsure whether not following the wound care orders would have contributed to Resident #1's wound deterioration due to his other comorbidities including being a smoker, diabetes, hypertension, and peripheral vascular disease. The DON said the negative effect of not performing the ordered wound care or starting the antibiotic on Resident #1 would be the infection to his wound growing. During an interview attempt on 9/23/25 at 2:13 p.m. in the hospital Resident #1 was sleeping. During an interview on 9/23/25 at 2:15 p.m. the Hospital Nurse said Resident #1 was admitted for a non-healing surgical wound following a below the knee amputation and infection to the surgical wound. The Hospital Nurse said Resident #1 was given the option to have a surgical revision performed on his BKA to remove the infection to his wound or to have an AKA performed. The Hospital Nurse said Resident #1 had chosen to move forward with and AKA and it was scheduled for 9/24/25. The Hospital Nurse said per the hospital physician's progress note Resident #1 reported he had been seen by the wound care doctor on 9/18/25 at the facility and was told his wound looked good. The Hospital Nurse said per the hospital physician's progress note Resident #1 said he had a follow-up with his surgeon on 9/19/25 and was informed his wound did not look good and was infected. During an interview attempt on 9/24/25 at 10:28 a.m. the surveyor left a message with office staff for the Vascular Surgery NP with no return phone call received. During an interview on 9/24/25 at 11:00 a.m. LVN A said she had performed wound care on Resident #1 (unknown date). LVN A said the wound care she had performed was wrapping the surgical site with a bandage. LVN A said wrapping the surgical site with a bandage was the only order for wound care for Resident #1. 2. Record review of the face sheet dated 9/24/25 indicated Resident #2 was an [AGE] year-old female re-admitted to the facility on [DATE] with diagnoses including fracture of the upper and lower end of the right fibula (thin outer bone of the lower leg that runs from the knee to the ankle), congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should), osteoarthritis, hypertension, and diabetes. Record review of the MDS dated [DATE] indicated Resident #2 understood others and was understood by other. The MDS indicated Resident #2 had a BIMS score of 09 and was moderately cognitively impaired. The MDS indicated Resident #2 did not have any ulcers, wounds, or skin problems. Record review of the care plan last revised 7/15/25 indicated Resident #2 was at risk for impaired skin integrity. Record review of the physician orders which include active, completed, and discontinued order dated 9/24/25 indicated Resident #2 had an order to cleanse wound with wound cleanse, apply xeroform, and cover with dry dressing ordered 9/20/25 and with an unknown discontinue date. The physician orders indicated Resident #2 had an order to cleanse the right later low leg wound (wound #1) with wound cleanser, apply xeroform, and cover with a dry dressing starting 9/25/25. The physician orders indicated Resident #2 had an order to clean the right lower leg wound (wound #2) with wound cleanser, apply medical honey and calcium alginate, and cover with a dry dressing starting 9/25/25. The physician orders indicated Resident #2 had an order for Doxycycline (an antibiotic used to treat infections) 100mg twice a day for 10 days for wound infection. Record review of the Wound Care NP's progress note dated 9/11/25 indicated Resident #2 had a closed surgical wound to her right lower leg with 40% granulation (pink or red tissue that forms in the [NAME] stages of wound healing) and 60% scab. The Wound Care NP's progress note indicated Resident #2 had an order to cleanse the surgical wound with wound cleanser, apply xeroform, and cover with border dressing daily and as needed. Record review of the Wound Care NP's progress note dated 9/18/25 indicated Resident #2 had two surgical wounds to the right lower leg. The progress note indicated the wound to the right lateral lower leg (wound #1) had 80% granulation and 20% slough (non-viable, dead tissue)/ The progress note indicated Resident #2 had an order for wound #1 to cleanse the surgical wound with wound cleanser, apply xeroform, and cover with border dressing daily and as needed. The progress note indicated the wound to the right lower leg (wound #2) had 20% granulation, 40% slough, and 40% scab. The progress note indicated Resident #2 had an order for wound #2 to cleanse surgical wound with cleanser, apply medical honey and calcium alginate, and cover with a dry bordered dressing daily and as needed. During an interview on 9/24/25 at 9:45 am the DON said she did not know why Resident #2's wound care orders for 9/11/25 were not implemented until 9/20/25 or why Resident #2's wound orders for 9/18/25 were not implemented. The DON said the importance of ensuring wound care orders were implemented was patient care. The DON said the antibiotic order for Resident #2's wound was requested by the facility for prophylaxis due to her wound being open and fear of the wound becoming infected. The DON said she had not been able to access the wound care provider's progress notes until last week. The DON said she had emailed the wound care provider on 9/4/25 regarding not being able to access the progress notes and the wound care provider was supposed to have the issue resolved. The DON said the issue was not resolved until last week. During an interview on 9/24/25 at 11:30 a.m. Resident #2 said her surgical wound was doing well and healing nicely. Resident #2 said the facility had reached out to the community consultant regarding her wounds. Resident #2 said the community consultant had ordered her an antibiotic due to part of the wound not healing like the other part. Resident #2 said her surgical wound was not infected. During an interview on 9/24/25 at 12:13 p.m. the Wound Care NP said she was not aware her wound care orders on Resident #1 were not being followed. The Wound Care NP said she had seen him 3 times in the facility. The Wound Care NP said on the initial visit she gave orders to cleanse the wound with wound cleanser, apply Xeroform, and cover with rolled gauze. The Wound Care NP said on her 2 subsequent visits Resident #1 did have Xeroform in place. The Wound Care NP said when she rounded with the nurses she gave her treatment plan verbally at bedside, had a conference with the DON prior to leaving, and sent her progress notes to the facility. The Wound Care NP said she was aware of the facility not being able to access her progress notes electronically and had sent them over manually. The Wound Care NP said due to Resident #1 vascular issues not receiving proper wound care would not have contributed to the deterioration of his wound. The Wound Care NP said it was possible that not receiving proper wound care led to Resident #1's surgical wound infection. The Wound Care NP said she was not aware her wound care orders on Resident #2 had not been followed or implemented until 9/20/25. The Wound Care NP said Resident #2's wound care orders could have led to the deterioration of her wounds. The Wound Care NP said she did not order an antibiotic for Resident #2, but the primary care team may have. The Wound Care NP said she could not determine whether Resident #2's wound was infected but that there was redness surrounding the wound with minimal serous (thin, watery pale yellow, clear liquid) drainage. The Wound Care NP said she expected the facility to follow the orders she gave for wound care. The Wound Care NP the goal of wound care was to reduce the chances of infection, prevent deterioration of wounds, and to heal wounds. During an interview on 9/24/25 at 1:04 p.m. the NP said she had ordered an antibiotic for Resident #2 due to wound infection. The NP said the facility had sent her a picture of Resident #2's wound and due to the redness and slough the wound appeared infected leading her to ordering an antibiotic. The NP said not implementing the proper wound care as ordered by the Wound Care NP possibly led to the infection in Resident #2's wound. Record review of the facility's Wound Care policy revised October 2010 indicated, The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Verify that there is a physician's order for this procedure.The following information should be recorded in the resident's medical record: 1. The date wound care was given, 2, The initials of the individual performing the wound care. 3. Any change in the resident's condition. The Administrator was notified on 9/24/25 at 2:37 p.m. that an Immediate Jeopardy situation was identified due to the above failure. The Administrator was provided the Immediate Jeopardy template on 9/24/25 at 2:46 p.m. The facility's Plan of Removal was accepted on 9/25/25 at 9:13 a.m. and included: Plan of RemovalAction: Director of Nursing and Assistant Director of Nursing have been educated by the Regional Nurse Consultant on: 1. Notification of MD and resident responsible party of Change of condition, specifically notification of any new or deteriorated wounds.2. Transcribing physician ordersPerson(s) Responsible: Regional Nurse ConsultantDate/Time: 09/24/25Action: Licensed Nurses have been educated by the Director of Nursing on: 1. Notification of MD and resident responsible party of Change of condition, specifically notification of any new or deteriorated wounds.2. Transcribing physician ordersLicensed nurses and newly hired licensed nurses will be educated prior to working their next scheduled shift. Person(s) Responsible: Director of NursingDate/Time: 09/24/25 Action: DON/ADON will review all current wounds during Standards of Care meeting and ensure:a. Wound assessments are completed weekly.b. Care plans are completed and updated with new interventions.c. Orders from Wound practitioners are transcribed correctly.d. MD is notified of any new or deteriorating wounds.e. Wound log is updated. Person(s) Responsible: Director of NursingDate/Time: 09/24/25 On 9/25/25 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review of 6 of 9 residents currently receiving wound care confirmed all wound care orders were entered in each residents' physician orders and on each resident, TARs as ordered by the wound care provider as of 9/25/25. Record review of the facility's wound log dated 9/25/25 indicated all wound orders and wound assessments were up to date. During an observation on 9/25/25 at 9:15 am Observed LVN A perform wound care on Resident #2. LVN A provided privacy before starting and explained procedure to Resident #2. LVN A performed appropriate hand hygiene and glove changes during the wound care. LVN A performed wound care per the most current orders from the Wound Care NP using aseptic technique. There was no concern with the wound care performed. Record review of in-services dated 9/23/25 indicated 4 LVNs had been in-serviced regarding weekly skin and wound assessments, notifying the physician or NP regarding wound deterioration, ensuring all residents with wounds had orders in place, and ensuring all treatment orders showed up on each resident's TAR. Staff interviewed (LVN A, LVN B, and LVN C) on 9/25/25 between 9:10 a.m. and 10:03 a.m. said they had been in-serviced regarding the importance of weekly skin and wound assessments, ensuring all wounds had a treatment order in the EMR and that the treatment order was on the resident's TAR, obtaining treatment orders for new residents or residents with new wounds, and reporting changes in condition including wound deterioration. During an interview on 9/25/25 at 10:09 a.m. the DON and ADON said they would be monitoring the residents' plan of care to ensure any new orders including wound care orders were entered. The DON and ADON said they would be reviewing wound care orders against the Wound Care NP's progress notes to ensure accuracy. The DON and ADON said they would be checking the EMR to ensure all residents had weekly skin assessments performed. On 9/25/25 at 10:18 a.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance the facility remained out of compliance with a scope identified as patterned and a severity level of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on interview and record review the facility failed to provide pharmaceutical services, including the accurate acquiring, administering and receipt of all drugs and biologicals, to meet the needs of 1 of 9 (Resident #1) residents reviewed for pharmacy services. The facility failed to ensure Resident #1's antibiotic (Cleocin) was started on 9/19/25 when ordered from the Vascular Surgery NP instead waiting 2 days until 9/21/25 to initiate the antibiotic. The facility failed to ensure the nurses had access to the Pyxis (a machine used to safely and efficiently dispense medications) to obtain available medication such as antibiotics while waiting for pharmacy to deliver medications. The facility failed to ensure Resident #1's antibiotic was initial dosed when delivered from the pharmacy on 9/20/25 instead initiating the antibiotic on 9/21/25 and Resident #1 required hospitalization due to infection on 9/22/25. This failure resulted in an identification of an Immediate Jeopardy (IJ) at 2:20 p.m. on 9/24/25. While the IJ was removed on 9/25/25, the facility remained out of compliance with a scope identified as isolated and a severity level of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place residents with an order for an antibiotic at risk for spread of infection leading to hospitalization, need for intravenous antibiotics, or sepsis (a life-threatening complication of infection). Findings Include:1. Record review of the face sheet dated 9/23/25 indicated Resident #1 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including orthopedic aftercare following surgical amputation (surgical procedure where a body part, such as a limb, finger, or toe is removed), right below the knee amputation, diabetes, peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and hypertension (elevated blood pressure). Record review of the MDS dated [DATE] indicated Resident #1 understood others and was understood by others. The MDS indicated Resident #1 had a BIMS score of 15 and was cognitively intact. The MDS indicated Resident #1 had a surgical wound. Record review of the care plan initiated on 9/16/25 indicated Resident #1 had a recent right below the knee amputation and was at risk for phantom pain (a painful perception an individual experiences relating to a limb or organ that is not physically part of their body), increase in disturbed self-image, increase in depression, and increase in need for assistance with ADLs. The care plan indicated Resident #1 had interventions in place including wound care/dressing changed to be performed to the stump/amputation area per physician orders. Record review of the physician orders which include active, completed, and discontinued order dated 9/23/25 indicated Resident #1 had an order for Cleocin ((Clindamycin) an antibiotic to treat infection) 150mg 2 capsules 3 times a day related to acquired absence of right leg below the knee. Record review of the MAR dated September 2025 indicated Resident #1 did not receive his Cleocin 300mg on 9/20/25 at 8:00 a.m. or 12:00 p.m. due to medication not being available. The MAR indicated Resident #1 received his Cleocin 300mg on 9/20/25 at 4:00 p.m. The MAR indicated Resident #1 did not received his Cleocin 300mg on 9/21/25 at 8:00 a.m. or 12:00 p.m. due to medication not being available. The MAR indicated Resident #1 received his Cleocin 300mg on 9/21/25 at 4:00 p.m. Record review of the Pyxis Inventory Sheet dated 5/5/25 indicated the Pyxis had Clindamycin 150mg capsules with 20 capsules available for dispensing. Record review of the Pharmacy Packing slip dated 9/19/25 and signed by unknown facility staff on 9/20/25 indicated Resident #1's Clindamycin 150mg capsules had been delivered to the facility. Record review of the Nursing Progress Note dated 9/19/25 at 4:08 p.m. written by LVN A indicated, [Resident #1] returned from the doctor's office with new orders. Cleocin 300mg by mouth three times a day for 10 days. Record review of the Administration Progress Note dated 9/20/25 at 7:07 a.m. written by MA D indicated the facility was waiting on Resident #1's Cleocin 150mg to be delivered from the pharmacy. Record review of the Administration Progress Note dated 9/20/25 at 11:38 a.m. written by MA D indicated the facility was waiting on Resident #1's Cleocin 150mg to be delivered from the pharmacy. Record review of the Administration Progress Note dated 9/21/25 at 7:25 a.m. written by MA D indicated the facility was waiting on Resident #1's Cleocin 150mg to be delivered from the pharmacy. Record review of the Administration Progress Note dated 9/21/25 at 11:48 a.m. written by MA D indicated the facility was waiting on Resident #1's Cleocin 150mg to be delivered from the pharmacy. Record review of the Administration Progress Note dated 9/21/25 at 2:15 p.m. written by LVN indicated Resident #1's Cleocin was initial dosed per orders. During an interview on 9/23/25 at 12:35 p.m. the DON said she could not say why Resident #1's Clindamycin was not started for 2 days when it was available in the Pyxis. The DON said the importance of ensuring antibiotics and other medications were started timely especially when available in the Pyxis was patient care. The DON said the negative effect of not performing the ordered wound care or starting the antibiotic on Resident #1 would be the infection to his wound growing. During an interview attempt in the hospital on 9/23/25 at 2:13 p.m. Resident #1 was sleeping. During an interview on 9/23/25 at 2:15 p.m. the Hospital Nurse said Resident #1 was admitted for a non-healing surgical wound following a BKA and infection to the surgical wound. The Hospital Nurse said he was unsure whether wound cultures had been collected but that blood cultures had been collected and were still pending. The Hospital Nurse said Resident #1 was given the option to have a surgical revision performed on his BKA to remove the infection to his wound or to have an AKA performed. The Hospital Nurse said Resident #1 had chosen to move forward with and AKA and it was scheduled for 9/24/25. The Hospital Nurse said Resident #1 was receiving Zosyn (an antibiotic to treat infections) via IV for the infection to his surgical wound. The Hospital Nurse said to his understanding Resident #1's surgeon had order antibiotics for the wound infection and the facility had not administered the antibiotics. During an interview on 9/24/25 at 8:25 a.m. the Regional Nurse said they had checked the Pyxis reports, and it indicated Clindamycin had not been removed from the Pyxis for Resident #1 on 9/19/25, 9/20/25, or 9/21/25. During an interview on 9/24/25 at 10:08 a.m. MA D said she had worked 6:00 a.m.-10:00 p.m. on 9/20/25 and 9/21/25. MA D said Resident #1's Clindamycin did not arrive at the facility until 9/21/25. MA D said there had been some kind of issue with medication being placed in the correct resident cubbies. MA D said neither of the nurses working the weekend had access to the Pyxis. MA D said Resident #1 did not receive his antibiotic on 9/20/25 and only received the evening dose on 9/21/25 when she found the medication in his cubby. MA D said Resident #1's Clindamycin was not previously in his cubby when she looked for it. MA D said the facility's EMR system will not allow them to go correct an error in marking a medication as given that was not given. MA D said she had accidentally marked that Resident #1's evening dose of Clindamycin was given on 9/20/25, but it had not been. During an interview attempt on 9/24/25 at 10:28 a.m. the surveyor left a message with office staff for the Vascular Surgery NP with no return phone call received. During an interview on 9/24/25 at 11:00 a.m. LVN A said Resident #1's Clindamycin was started on 9/21/25 for his evening dose. LVN A said on 9/21/25 during her shift 6:00 a.m-6:00 p.m. the medication had not come in from the pharmacy and she did not have access to the Pyxis. LVN A said she was new to the facility and management was aware she did not have access to the Pyxis. LVN A said Resident #1's Clindamycin had actually been delivered on 9/20/25 but was not put on the medication cart. LVN A said she found the medication after he had missed his morning and noon doses in his cubby. LVN A said the importance of ensuring antibiotics were started in a timely manner was to prevent the worsening of an infection. Record review of the facility's Administering Medication policy revised April 2019 indicated, Medications are administered in a safe and timely manner, and as prescribed.Medications are administered in accordance with prescriber orders, including any required time frame. The Administrator was notified on 9/24/25 at 2:37 p.m. that an Immediate Jeopardy situation was identified due to the above failure. The Administrator was provided the Immediate Jeopardy template on 9/24/25 at 2:46 p.m. The facility's Plan of Removal was accepted on 9/24/25 at 8:01 p.m. and included: Action: The Director of Nursing immediately set up access for all licensed nurses to access the Pyxis systemPerson(s) Responsible: Director of NursingDate/Time: 09/24/25 Action: Director of Nursing and Assistant Director of Nursing have been educated by the Regional Nurse Consultant on: 1. New employee (licensed nurses) set up and access to the Pyxis on hire prior to start of first shift. 2. Transcribing new medication orders to PCC when received3. Licensed nurse nurses will check Pyxis system upon receipt of orders and determine if medication is available for initial dose. 4. Administration of initial dose of antibiotic medications timely by the licensed nurse5. Obtaining medications from Pyxis when medication is not available in the medication cart6. If medications are not stocked in the Pyxis the nurse will notify the pharmacy via telephone and request a STAT delivery and get an ETA for delivery. The nurse will notify the Director of Nursing and the physician if antibiotic medications are not available within 2 hours for follow up orders.Person(s) Responsible: Regional Nurse ConsultantDate/Time: 09/24/25Action: Licensed Nurses have been educated by the Director of Nursing on: 1. Transcribing new medication orders to PCC when received2. Licensed nurse nurses will check Pyxis system upon receipt of orders and determine if medication is available for initial dose. 3. Administration of initial dose of antibiotic medications timely by the licensed nurse4. Obtaining medications from Pyxis when medication is not available in the medication cart5. If medications are not stocked in the Pyxis the nurse will notify the pharmacy via telephone and request a STAT delivery and get an ETA for delivery. The nurse will notify the Director of Nursing and the physician if antibiotic medications are not available within 2 hours for follow-up ordersLicensed nurses/MAs and newly hired licensed nurses/MAs will be educated prior to working their next scheduled shiftPerson(s) Responsible: Regional Nurse Consultant, Director of Nursing, Assistant Director of Nursing, and/or DesigneeDate/Time: 09/24/25 Action: The Director of Nursing, Assistant Director of Nursing will review all new orders and MARS daily during morning clinical meeting to ensure all new medication orders have been transcribed, ordered and initial doses administered in a timely manner. Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, and/or Designee Date/Time: 09/24/25 On 9/25/25 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review of the audit for 5 of 9 residents with a new antibiotic order in the past 90 days indicated all residents received their initial dose of medication within 24 hours of receiving the order. Record review of an in-service dated 9/23/25 indicated 5 staff members had been in-serviced regarding accessing the Pyxis to obtain medications newly ordered, ensuring all antibiotic orders were entered into the electronic medical records, ensuring all new medications including antibiotics were initial dosed by a licensed nurse, and ensuring medications are ordered STAT if they do not come in from the pharmacy. Staff interviewed (LVN A, LVN B, LVN C, and MA D) on 9/25/25 between 9:10 a.m. and 10:03 a.m. said they had in-serviced regarding new medication orders. They said for a new medication order the nurse was to obtain the medication from the Pyxis if available, order the medication from the pharmacy and if it did not come in to call the pharmacy and make the medication a stat order, and initial dose all new medications. All nurses interviewed said they had access to the Pyxis. During an interview on 9/25/25 at 10:09 a.m. the DON said all nurses now had access to the Pyxis. The DON said any newly hired nurses would immediately receive access to the Pyxis. The DON said she and the ADON would be checking for new medication orders daily and ensure the orders if available in the Pyxis had been initial dosed and if not available in the Pyxis had been ordered stat from the pharmacy. On 9/25/25 at 10:18 a.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance the facility remained out of compliance with a scope identified as isolated with a severity level of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in the facility's only kitchen observed for kitchen sanitation. The facility failed to ensure: - items in the reach in cooler had a label and an open date. -items on the prep table had been opened and not labeled with the open date. These failures could place residents who ate food from the kitchen at risk of foodborne illness. Findings included: During observations, interviews and record reviews on 05/027/25 of the kitchen the following was noted: On 05/27/25 at 10:16 AM in the 3-door cooler 1-46 oz honey thick Orange Juice was not dated when opened. It had a truck delivery date on the container of 05/07/2025. 1-46 oz. nectar thick Orange Juice was not dated when opened. It had a truck delivery date on the container of 05/14/2025. The packaging on the container reads: After opening may be kept up to 7 days under refrigeration. 1 small white bowl of white substance plastic covering dated 05/20/25. 1 small square plastic covered container with no label or date contained a small brown square of some substance. During an observation on 05/27/2025 at 10:40 AM on the prep table opposite the dish machine the following was noted: 1-46 oz honey thick sweet tea was not dated when opened. It had a truck delivery date on the container of 5/14/25. 1-46 oz. nectar thick sweet tea was not dated when opened. It had a truck delivery date on the container of 5/21/25. The packaging on the container reads: After opening may be kept up to 7 days under refrigeration. During an interview and observation on 05/27/2025 at 10:27 AM the DM removed all four thickened liquid cartons that were open and discarded them. She said the date marked on the box was the date the truck delivered the item and was to help with product rotation. She said items were to be marked when opened. She said leftovers in the refrigerator should be used within 3 days or discarded. She said the white substance was a bowl of icing and should have been discarded. She said the item in the small square container was a piece of fudge that belonged to a resident. She discarded the icing and fudge. Record review the facility's Food Receiving and Storage policy, revised November 2022, indicated the following: .Refrigerated /Frozen Storage 1. All foods stored in the refrigerator or freezer are covered, labeled and dated (use by date) .7. Refrigerated foods are labeled, dated and monitored so they are used by their use-by date, frozen, or discarded.

Based on observation, interview and record review, the facility failed to ensure resident rooms measured at least 80 square feet per resident in multiple rooms and at least 100 square feet in single resident rooms for 2 of 10 resident rooms (Resident room [ROOM NUMBER] and 311) reviewed for square footage. The facility failed to provide 80 square feet per resident for a room certified for 4 residents and provide 100 square feet for a room certified as a private room. These failures could place residents at risk of not having adequate space to meet their needs. Findings included: During an observation on initial tour on 05/27/2025 at 10:40 AM, it was observed that no residents were residing in room [ROOM NUMBER] and no residents were residing in room [ROOM NUMBER]. During an interview on 05/28/2025 at 9:45 AM, the Administrator said resident rooms [ROOM NUMBERS] still required room waivers. She said room [ROOM NUMBER] was certified for 4 residents and measured 74 square feet per resident and room [ROOM NUMBER] was certified as a private room and measured 81 feet instead of 100 square feet. She said room [ROOM NUMBER] was used as a staff break room. She said she filed for the waiver after the life safety code inspection on 05/27/2025. Record review of the bed classification form dated 05/27/2025 indicated room [ROOM NUMBER] was certified for 4 residents and room [ROOM NUMBER] was certified for 1 resident.

Based on observation, interview and record review, the facility failed to ensure resident rooms measured at least 80 square feet per resident in multiple rooms and at least 100 square feet in single resident rooms for 2 of 10 resident rooms (Resident room [ROOM NUMBER] and 311) reviewed for square footage. The facility failed to provide 80 square feet per resident for a room certified for 4 residents and provide 100 square feet for a room certified as a private room. These failures could place residents at risk of not having adequate space to meet their needs. Findings include: During an observation on initial tour on 04/14/2024 at 10:20 AM, it was observed that 2 residents resided in room [ROOM NUMBER] and no residents were residing in room [ROOM NUMBER]. During an interview on 04/16/2024 at 2:30 PM, the Administrator said resident rooms [ROOM NUMBERS] still required room waivers. She said room [ROOM NUMBER] was certified for 4 residents and measured 74 square feet per resident and room [ROOM NUMBER] was certified as a private room and measured 81 feet instead of 100 square feet. Record review of a resident roster, dated 04/16/2024, indicated room [ROOM NUMBER] was certified for 4 residents and room [ROOM NUMBER] was certified for 1 resident.

Based on interview and record review the facility failed to ensure resident rooms measured at least 80 square feet per resident in multiple rooms and at least 100 square feet in single resident rooms for 2 of 10 resident rooms (Resident room [ROOM NUMBER] and 311) reviewed for square footage. The facility failed to provide 80 square feet per resident for a room certified for 4 residents and provide 100 square feet for a room certified as a private room. These failures could place residents at risk of not having adequate space to meet their needs. Findings include: During an observation on initial tour on 03/13/2023 at 9:20 A.M. revealed 2 residents resided in room [ROOM NUMBER] and no residents were residing in room [ROOM NUMBER]. During an interview on 03/15/2023 at 8:30 A. M., the Administrator said resident rooms [ROOM NUMBERS] still required room waivers. She said room [ROOM NUMBER] was certified for 4 residents and measured 74 square feet per resident and room [ROOM NUMBER] was certified as a private room and measured 81 feet instead of 100 square feet. Record review of a resident roster, dated 03/13/2023, indicated room [ROOM NUMBER] was certified for 4 residents and room [ROOM NUMBER] was certified for 1 resident.

Based on interview and record review, the facility failed to provide the required square footage per resident for 2 of 2 resident rooms reviewed for square footage. (Resident room 308 and 311). Room 308 was certified for 4 residents and measured 74 square feet per resident instead of 80 square feet. Room 311 was certified as a private room and measured 81 square feet instead of 100 square feet. This failure could place residents at risk of not having adequate space to meet their needs. Findings included: During an interview on 01/20/2022 at 1:43 P.M., the Administrator said resident rooms 308 and 311 still required room waivers. She said room 308 was certified for 4 residents and measures 74 square feet/resident and room 311 was certified as a private room and measures 81 square feet instead of 100 square feet. During an observation on initial tour on 01/18/2022 at 09:25 A.M., 2 residents were residing in room 308 and no residents were residing in room 311. A resident roster dated 01/18/2022 indicated 2 residents resided in room 308 and no residents resided in room 311 The bed classification form dated 01/18/2022 indicated room 308 was certified for 4 residents and room 311 was certified for 1 resident.